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:
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsWhittier, CATarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsAnn Arbor, MITarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsAtlanta, GATarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsCleveland, OHTarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsIndianapolis, INTarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsLos Angeles, CATarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsNew Haven, CTTarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
Johns Hopkins Community Health Partnership
Johns Hopkins HealthCare LLC Baltimore, MDTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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 Johns Hopkins Community Health Partnership has not been replicated.
Outcome Notes: Program evaluation as part of a CMS grant indicated reductions in hospitalizations and ED visits for Medicare and Medicaid patients, and reduced costs.
Point of Contact: Melissa Sherry , Director, Population Health Innovation and Transformation 419-297-0162msherry@jhhc.com
Maximizing Independence at Home
Johns Hopkins MedicineBaltimore, MDTarget Population: - 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: Maximizing Independence at Home has not been replicated.
Outcome Notes: Studies have found: delay of nursing home entry; better self reported quality of life; and fewer hours of direct care per week. Cost evaluations ongoing.
Point of Contact: Constantine G. Lyketsos, Elizabeth Plank Althouse Professor410-550-0062kostas@jhmi.edu
Guided Care
Johns Hopkins University Baltimore, MDTarget 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
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:
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Johns Hopkins Community Health Partnership
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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 Johns Hopkins Community Health Partnership has not been replicated.
Program evaluation as part of a CMS grant indicated reductions in hospitalizations and ED visits for Medicare and Medicaid patients, and reduced costs.
Maximizing Independence at Home
- 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
Maximizing Independence at Home has not been replicated.
Studies have found: delay of nursing home entry; better self reported quality of life; and fewer hours of direct care per week. Cost evaluations ongoing.
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.