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:
Commonwealth Care Alliance
Commonwealth Care AllianceRutland, MATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicaid
- Medicare / Medicaid
- Uninsured
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 number of studies have found positive results for CCA's interventions, including: decreased hospital admissions; decreased hospital readmissions; and a decrease in overall expenses for acute care needs.
Point of Contact: Christopher Palmieri, President/CEO617-895-6885cpalmieri@commonwealthcare.org
Optimal Health: Behavioral Health Home Plus
Community Care Behavioral Health Organization Bellefonte, PATarget Population: - People with Multiple Chronic Conditions
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 operates at fifty-two locations across Pennsylvania.
Outcome Notes: A formal study indicated: increased activation in care; increased engagement and frequency of visits with primary and specialty care; decreased behavioral and medical inpatient use and cost; and increased ambulatory physical health service use.
Point of Contact: Patricia Schake , Senior Director Program Innovation 412-402-7546schakepl@ccbh.com
ED Visit Reduction Program, Summit, Readmission Avoidance Program
Consistent Care Services SPC, PSKennewick, WATarget 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: Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Outcome Notes: Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
Point of Contact: Michelle Gardner, Project Manager406-925-0868michelle.gardner@consistentcare.org
ED Visit Reduction Program, Summit, Readmission Avoidance Program
Consistent Care Services SPC, PSMarysville, WATarget 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: Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Outcome Notes: Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
Point of Contact: Michelle Gardner, Project Manager406-925-0868michelle.gardner@consistentcare.org
ED Visit Reduction Program, Summit, Readmission Avoidance Program
Consistent Care Services SPC, PSSpokane, WATarget 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: Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Outcome Notes: Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
Point of Contact: Michelle Gardner, Project Manager406-925-0868michelle.gardner@consistentcare.org
ED Visit Reduction Program, Summit, Readmission Avoidance Program
Consistent Care Services SPC, PSWalla Walla, WATarget 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: Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Outcome Notes: Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
Point of Contact: Michelle Gardner, Project Manager406-925-0868michelle.gardner@consistentcare.org
ED Visit Reduction Program, Summit, Readmission Avoidance Program
Consistent Care Services SPC, PSYakima, WATarget 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: Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Outcome Notes: Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
Point of Contact: Michelle Gardner, Project Manager406-925-0868michelle.gardner@consistentcare.org
10th Decile Project
Corporation for Supportive Housing Glendale, 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
10th Decile Project
Corporation for Supportive Housing Los 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
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
10th Decile Project
Corporation for Supportive Housing Pasadena, 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
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:
Commonwealth Care Alliance
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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 number of studies have found positive results for CCA's interventions, including: decreased hospital admissions; decreased hospital readmissions; and a decrease in overall expenses for acute care needs.
Optimal Health: Behavioral Health Home Plus
- People with Multiple Chronic Conditions
- 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 operates at fifty-two locations across Pennsylvania.
A formal study indicated: increased activation in care; increased engagement and frequency of visits with primary and specialty care; decreased behavioral and medical inpatient use and cost; and increased ambulatory physical health service use.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
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.
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.
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.