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:
Care Management Plus
Oregon Health & Science UniversityDover-Foxcroft, METarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityCadillac, MITarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityBrainerd, MNTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityWillard, NMTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityAustin, NVTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityOneida, NYTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityColumbus, OHTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityPrineville, ORTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityBrady, TXTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Care Management Plus
Oregon Health & Science UniversityManti, UTTarget 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.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:
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.