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:
CareMore
CareMoreLas Vegas, NVTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes: A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact: Sachin Jain, President/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreMemphis, TNTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes: A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact: Sachin Jain, President/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreNew Haven, CTTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes: A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact: Sachin Jain, President/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreRichmond, VATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes: A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact: Sachin Jain, President/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreNorth Fork, CATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes: A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact: Sachin Jain, President/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreTucson, AZTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes: A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact: Sachin Jain, President/CEO617-901-7000sachin.jain@caremore.com
Health Resilience Program
CareOregon Astoria, ORTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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 Health Resilience Program has been replicated in five sites in Oregon.
Outcome Notes: A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.
Point of Contact: Rebecca Ramsay , Executive Director, Housecall Providers 503-781-6435ramsayr@careoregon.org
Health Resilience Program
CareOregon Medford, ORTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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 Health Resilience Program has been replicated in five sites in Oregon.
Outcome Notes: A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.
Point of Contact: Rebecca Ramsay , Executive Director, Housecall Providers 503-781-6435ramsayr@careoregon.org
Health Resilience Program
CareOregon Oregon City, ORTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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 Health Resilience Program has been replicated in five sites in Oregon.
Outcome Notes: A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.
Point of Contact: Rebecca Ramsay , Executive Director, Housecall Providers 503-781-6435ramsayr@careoregon.org
Health Resilience Program
CareOregon Portland, ORTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
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 Health Resilience Program has been replicated in five sites in Oregon.
Outcome Notes: A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.
Point of Contact: Rebecca Ramsay , Executive Director, Housecall Providers 503-781-6435ramsayr@careoregon.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:
CareMore
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
CareMore
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
CareMore
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
CareMore
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
CareMore
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
CareMore
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Health Resilience Program
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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 Health Resilience Program has been replicated in five sites in Oregon.
A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.
Health Resilience Program
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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 Health Resilience Program has been replicated in five sites in Oregon.
A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.
Health Resilience Program
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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 Health Resilience Program has been replicated in five sites in Oregon.
A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.
Health Resilience Program
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- 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 Health Resilience Program has been replicated in five sites in Oregon.
A program evaluation found decreased ED visits and inpatient admissions and increased primary care visits, along with decreased costs.