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:
Guided Care
Johns Hopkins University Boston, MATarget 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
Replicated Sites: Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Outcome Notes: Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Point of Contact: Cynthia Boyd, Professor of Medicine410-550-8676cyboyd@jhmi.edu
Guided Care
Johns Hopkins University Jamestown, 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
Replicated Sites: Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Outcome Notes: Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Point of Contact: Cynthia Boyd, Professor of Medicine410-550-8676cyboyd@jhmi.edu
Guided Care
Johns Hopkins University Lynchburg, VATarget 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
Replicated Sites: Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Outcome Notes: Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Point of Contact: Cynthia Boyd, Professor of Medicine410-550-8676cyboyd@jhmi.edu
Guided Care
Johns Hopkins University Midland, MITarget 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
Replicated Sites: Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Outcome Notes: Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Point of Contact: Cynthia Boyd, Professor of Medicine410-550-8676cyboyd@jhmi.edu
Guided Care
Johns Hopkins University New Bern, NCTarget 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
Replicated Sites: Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Outcome Notes: Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Point of Contact: Cynthia Boyd, Professor of Medicine410-550-8676cyboyd@jhmi.edu
Hospital at Home
Johns Hopkins University School of MedicineCincinnati, 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 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 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 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 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
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:
Guided Care
- 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
Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Guided Care
- 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
Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Guided Care
- 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
Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Guided Care
- 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
Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
Guided Care
- 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
Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.
Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.
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.