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:
10th Decile Project
Corporation for Supportive Housing Santa Monica, 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
Replicated Sites: The 10th Decile Project has been replicated in four sites in the Los Angeles area (Glendale, CA; Los Angeles, CA; Pasadena, CA; and Santa Monica, CA).
Outcome Notes: A program evaluation found decreased ED and hospital utilization, and reduced costs. The program evaluation also reported high primary care utilization among enrollees.
Point of Contact: Susan Lee , Senior Program Manager 213-623-4342susan.lee@csh.org
HomeBASE
Duke Outpatient ClinicDurham, NCTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: This program has not been replicated.
Outcome Notes: A study of the program found an association with decreased ED utilization and increased primary care engagement.
Point of Contact: Marigny Manson Bratcher, Nursing Program Coordinator919-309-6562marigny.manson@duke.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityLebanon, KYTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityRutland, MATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityDavidsonville, MDTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityCadillac, MITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityBrainerd, MNTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityJefferson City, MOTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversitySanford, NCTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityJackson, NJTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.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:
10th Decile Project
- 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
The 10th Decile Project has been replicated in four sites in the Los Angeles area (Glendale, CA; Los Angeles, CA; Pasadena, CA; and Santa Monica, CA).
A program evaluation found decreased ED and hospital utilization, and reduced costs. The program evaluation also reported high primary care utilization among enrollees.
HomeBASE
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
This program has not been replicated.
A study of the program found an association with decreased ED utilization and increased primary care engagement.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.