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:
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityWillard, NMTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityOneida, NYTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityColumbus, OHTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityPrineville, ORTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityBellefonte, PATarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityCrompton, RITarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityColumbia, SCTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityMurfreesboro, TNTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityBrady, TXTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityBuckingham, VATarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.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:
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.