Use the filters below to learn about programs across the country that are working to care for people with complex medical, behavioral health, and social needs. Learn more about how this map was developed. The Playbook also welcomes submissions from the field — learn how to submit your program.
Narrow by:
Hospital at Home
Johns Hopkins University School of MedicineColumbus, OHTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
Outcome Notes: A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Point of Contact: Bruce Leff, Professor of Medicine410-550-2654bleff@jhmi.edu
Hospital at Home
Johns Hopkins University School of MedicineHonolulu, HITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
Outcome Notes: A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Point of Contact: Bruce Leff, Professor of Medicine410-550-2654bleff@jhmi.edu
Hospital at Home
Johns Hopkins University School of MedicineLos Angeles, CATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
Outcome Notes: A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Point of Contact: Bruce Leff, Professor of Medicine410-550-2654bleff@jhmi.edu
Hospital at Home
Johns Hopkins University School of MedicineNew Orleans, LATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
Outcome Notes: A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Point of Contact: Bruce Leff, Professor of Medicine410-550-2654bleff@jhmi.edu
Hospital at Home
Johns Hopkins University School of MedicineNew York, NYTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
Outcome Notes: A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Point of Contact: Bruce Leff, Professor of Medicine410-550-2654bleff@jhmi.edu
Hospital at Home
Johns Hopkins University School of MedicinePhiladelphia, PATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
Outcome Notes: A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Point of Contact: Bruce Leff, Professor of Medicine410-550-2654bleff@jhmi.edu
Hospital at Home
Johns Hopkins University School of MedicinePortland, ORTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
Outcome Notes: A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Point of Contact: Bruce Leff, Professor of Medicine410-550-2654bleff@jhmi.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programSaginaw, MITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programSan Diego, CATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programScranton, PATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- Commercial
Care Program Elements: - Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Use the filters below to learn about programs across the country that are working to care for people with complex medical, behavioral health, and social needs. Learn more about how this map was developed. The Playbook also welcomes submissions from the field — learn how to submit your program.
Narrow by:
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).
A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- Commercial
- Individualized care plan
- Ongoing care plan review
- Interdisciplinary care team
- Active care coordination
- Assesses behavioral health care needs and coordinates services
- Addresses social determinants of health
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.