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:
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingJefferson City, MOTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingCarthage, MSTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingLewistown, MTTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingSanford, NCTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingColumbia, SCTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingMcClusky. NDTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingPierre, SDTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingBroken Bow, NETarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingMurfreesboro, TNTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.edu
The Transitional Care Model (TCM)
University of Pennsylvania School of NursingAshland, NHTarget Population: - 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
Outcome Notes: A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
Point of Contact: Karen Hirschman, Associate Professor215-573-3755hirschk@nursing.upenn.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:
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.
The Transitional Care Model (TCM)
- 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 Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).
A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.