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.
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Commonwealth Care Alliance
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
This program has not been replicated.
A number of studies have found positive results for CCA's interventions, including: decreased hospital admissions; decreased hospital readmissions; and a decrease in overall expenses for acute care needs.
Optimal Health: Behavioral Health Home Plus
- People with Multiple Chronic Conditions
- 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
This program operates at fifty-two locations across Pennsylvania.
A formal study indicated: increased activation in care; increased engagement and frequency of visits with primary and specialty care; decreased behavioral and medical inpatient use and cost; and increased ambulatory physical health service use.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
ED Visit Reduction Program, Summit, Readmission Avoidance Program
- 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
Consistent Care has been replicated in five sites in Washington (Spokane, WA; Kennewick, WA; Walla Walla, WA; Yakima, WA; Marysville, WA).
Peer-reviewed studies including a randomized control trial have shown roughly a 34% reduction in ED visits, reductions in the number of patients who receive opioid prescriptions, and reductions in overall costs.
10th Decile Project
- 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
The 10th Decile Project has been replicated in four sites in the Los Angeles area (Glendale, CA; Los Angeles, CA; Pasadena, CA; and Santa Monica, CA).
A program evaluation found decreased ED and hospital utilization, and reduced costs. The program evaluation also reported high primary care utilization among enrollees.
10th Decile Project
- 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
The 10th Decile Project has been replicated in four sites in the Los Angeles area (Glendale, CA; Los Angeles, CA; Pasadena, CA; and Santa Monica, CA).
A program evaluation found decreased ED and hospital utilization, and reduced costs. The program evaluation also reported high primary care utilization among enrollees.
10th Decile Project
- 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
The 10th Decile Project has been replicated in four sites in the Los Angeles area (Glendale, CA; Los Angeles, CA; Pasadena, CA; and Santa Monica, CA).
A program evaluation found decreased ED and hospital utilization, and reduced costs. The program evaluation also reported high primary care utilization among enrollees.