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:
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programBath, METarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programBrattleboro, VTTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programDenver, COTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Care Connections Program
Los Angeles County Department of Health Services Los Angeles, CATarget Population: - People with Multiple Chronic Conditions
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: The Care Connections has not been replicated.
Outcome Notes: Early results found: a reduction in acute care utilization; an increase in primary care utilization; a reduction in A1C levels; and improved care coordination and communication. Additional studies including a formal, external evaluation, are underway.
Point of Contact: Ami Shah, (former) Deputy Director, Care Connections 347-262-6266ashah3@dha.lacounty.gov
Brooklyn Health Home
Maimonides Medical CenterBrooklyn, NY Target Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - 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
- 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 Brooklyn Health Home program has not been replicated.
Outcome Notes: A program evaluation showed reductions in ED and hospital utilization for enrolled Medicaid patients.
Point of Contact: Shari Suchoff, Vice President 718-283-6000ssuchoff@maimonidesmed.org
Health Homes
MaineCare ServicesDover-Foxcroft, METarget Population: - People with Multiple Chronic Conditions
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: The Health Homes program operates statewide in Maine.
Outcome Notes: A large program evaluation showed improved quality metrics that relate to care coordination and/or stronger primary care (e.g., non-emergent ED Use, Fragmented Care Index (FCI), Follow-up after hospitalization for mental illness) for those members who participated in the Health Homes program.
Point of Contact: Loretta Dutill, Operations Manager207-624-6954Loretta.A.Dutill@maine.gov
Bridges to Care
Metro Community Provider Network and University of Colorado HospitalAurora, COTarget Population: - People with Multiple Chronic Conditions
Insurance: - Medicare
- 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: Bridges to Care operates at two locations in the Denver area.
Outcome Notes: A peer reviewed analysis associated lower ED utilization and higher primary care utilization to participation in the intervention; within a subcategory of patients with mental health comorbidities, the study found associated decreases in ED and hospital inpatient utilization, and increases in primary care utilization.
Point of Contact: Roberta Capp , Director of Care Transitions, University of Colorado Hospital617-894-8326roberta.capp@ucdenver.edu
Bridges to Care
Metro Community Provider Network and University of Colorado HospitalDenver, COTarget Population: - People with Multiple Chronic Conditions
Insurance: - Medicare
- 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: Bridges to Care operates at two locations in the Denver area.
Outcome Notes: A peer reviewed analysis associated lower ED utilization and higher primary care utilization to participation in the intervention; within a subcategory of patients with mental health comorbidities, the study found associated decreases in ED and hospital inpatient utilization, and increases in primary care utilization.
Point of Contact: Roberta Capp , Director of Care Transitions, University of Colorado Hospital617-894-8326roberta.capp@ucdenver.edu
Patient Health Improvement Initiative
Multicultural Health FoundationSan Diego, CATarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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: The Patient Health Improvement Initiative program has not been replicated.
Outcome Notes: Preliminary data showed reductions in ED visits, hospital admissions, and hospital length of stay.
Point of Contact: Natache Muschette, Executive Director240-604-2816natachemhf@gmail.com
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationMcClusky, NDTarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.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:
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Care Connections Program
- People with Multiple Chronic Conditions
- 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
The Care Connections has not been replicated.
Early results found: a reduction in acute care utilization; an increase in primary care utilization; a reduction in A1C levels; and improved care coordination and communication. Additional studies including a formal, external evaluation, are underway.
Brooklyn Health Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicaid
- Medicare / Medicaid
- 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 Brooklyn Health Home program has not been replicated.
A program evaluation showed reductions in ED and hospital utilization for enrolled Medicaid patients.
Health Homes
- People with Multiple Chronic Conditions
- 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
The Health Homes program operates statewide in Maine.
A large program evaluation showed improved quality metrics that relate to care coordination and/or stronger primary care (e.g., non-emergent ED Use, Fragmented Care Index (FCI), Follow-up after hospitalization for mental illness) for those members who participated in the Health Homes program.
Bridges to Care
- People with Multiple Chronic Conditions
- Medicare
- 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
Bridges to Care operates at two locations in the Denver area.
A peer reviewed analysis associated lower ED utilization and higher primary care utilization to participation in the intervention; within a subcategory of patients with mental health comorbidities, the study found associated decreases in ED and hospital inpatient utilization, and increases in primary care utilization.
Bridges to Care
- People with Multiple Chronic Conditions
- Medicare
- 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
Bridges to Care operates at two locations in the Denver area.
A peer reviewed analysis associated lower ED utilization and higher primary care utilization to participation in the intervention; within a subcategory of patients with mental health comorbidities, the study found associated decreases in ED and hospital inpatient utilization, and increases in primary care utilization.
Patient Health Improvement Initiative
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
The Patient Health Improvement Initiative program has not been replicated.
Preliminary data showed reductions in ED visits, hospital admissions, and hospital length of stay.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.