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:
VCU Complex Care Clinic
VCU Health SystemRichmond, VATarget Population: - People with Multiple Chronic Conditions
Insurance: - 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: VCU Health's Complex Care Clinic has not been replicated.
Outcome Notes: An internal evalaution showed modest cost savings over a three year period. A formal external evaluation is currently being conducted.
Point of Contact: Kimberly Lewis, Community Outreach Manager804-828-6063kimberly.lewis@vcuhealth.org
Community-based Care Coordination for Complex Health and Socioeconomic Needs
Verde Valley Caregivers CoalitionSedona, AZTarget 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: Verde Valley Caregivers Coalition's Community-Based Care Coordination has not been replicated.
Outcome Notes: None yet
Point of Contact: Kent Ellsworth, Executive Director928-204-1238kentellsworth@vvcaregivers.org
Intensive Outpatient Care Management (IOPCM)
West County Health Centers Guerneville, CATarget 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: West County Health Centers operate the Intensive Outpatient Care Management program in three health centers in Northern California.
Outcome Notes: Preliminary results have found reduced hospital and ER utilization, improved patient activation and self-reported health-related quality of life.
Point of Contact: Jason Cunningham , Chief Medical Officer 707-328-7205jcunningham@wchealth.org
Intensive Outpatient Care Management (IOPCM)
West County Health Centers Occidental, CATarget 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: West County Health Centers operate the Intensive Outpatient Care Management program in three health centers in Northern California.
Outcome Notes: Preliminary results have found reduced hospital and ER utilization, improved patient activation and self-reported health-related quality of life.
Point of Contact: Jason Cunningham , Chief Medical Officer 707-328-7205jcunningham@wchealth.org
Intensive Outpatient Care Management (IOPCM)
West County Health Centers Sebastopol, CATarget 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: West County Health Centers operate the Intensive Outpatient Care Management program in three health centers in Northern California.
Outcome Notes: Preliminary results have found reduced hospital and ER utilization, improved patient activation and self-reported health-related quality of life.
Point of Contact: Jason Cunningham , Chief Medical Officer 707-328-7205jcunningham@wchealth.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:
VCU Complex Care Clinic
- People with Multiple Chronic Conditions
- 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
VCU Health's Complex Care Clinic has not been replicated.
An internal evalaution showed modest cost savings over a three year period. A formal external evaluation is currently being conducted.
Community-based Care Coordination for Complex Health and Socioeconomic Needs
- 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
Verde Valley Caregivers Coalition's Community-Based Care Coordination has not been replicated.
None yet
Intensive Outpatient Care Management (IOPCM)
- 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
West County Health Centers operate the Intensive Outpatient Care Management program in three health centers in Northern California.
Preliminary results have found reduced hospital and ER utilization, improved patient activation and self-reported health-related quality of life.
Intensive Outpatient Care Management (IOPCM)
- 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
West County Health Centers operate the Intensive Outpatient Care Management program in three health centers in Northern California.
Preliminary results have found reduced hospital and ER utilization, improved patient activation and self-reported health-related quality of life.
Intensive Outpatient Care Management (IOPCM)
- 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
West County Health Centers operate the Intensive Outpatient Care Management program in three health centers in Northern California.
Preliminary results have found reduced hospital and ER utilization, improved patient activation and self-reported health-related quality of life.