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:
Health Resilience Program
CareOregon Scapoose, 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
Support and Services at Home (SASH)
Cathedral Square - SASH, Support and Services at HomeRoxbury, VTTarget 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 SASH program operates statewide in Vermont.
Outcome Notes: The program has seen improvements in access to primary care and improved self-management of chronic conditions. Additionally an independent, 3rd party evaluation found that participants showed statistically significant lower rates of growth in Medicare expenditures ($1,227 per beneficiary per year) than a control group.
Point of Contact: Molly Dugan, Director, SASH Program802-859-8803dugan@cathedralsquare.org
Restoration Center and Services
Center for Health Care ServicesBaton Rouge, LATarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.org
Restoration Center and Services
Center for Health Care ServicesDes Moines, IATarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.org
Restoration Center and Services
Center for Health Care ServicesNewburgh, NYTarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.org
Restoration Center and Services
Center for Health Care ServicesRapid City, SDTarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.org
Restoration Center and Services
Center for Health Care ServicesSalt Lake City, UTTarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.org
Restoration Center and Services
Center for Health Care ServicesSan Antonio, TXTarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.org
Restoration Center and Services
Center for Health Care ServicesWichita, KSTarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.org
Restoration Center and Services
Center for Health Care ServicesKansas City, KSTarget Population: - Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
Replicated Sites: The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Outcome Notes: Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Point of Contact: Leon Evans, Retired CEO, now a consultant210-392-4359L_evans@chcsbc.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:
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.
Support and Services at Home (SASH)
- 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 SASH program operates statewide in Vermont.
The program has seen improvements in access to primary care and improved self-management of chronic conditions. Additionally an independent, 3rd party evaluation found that participants showed statistically significant lower rates of growth in Medicare expenditures ($1,227 per beneficiary per year) than a control group.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.
Restoration Center and Services
- Adults Under 65 with Disabilities
- 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
- Engages in performance measurement/quality
The Center for Health Care Services approach has been replicated in eight counties around the country (Bexar County, TX; Wyandot County, KS; Des Moines, IA; Sedswick County, KA; Salt Lake County, UT; Rapid City, SD; Orange County, NY; Baton Rouge, LA).
Initial evaluations of the program indicated reductions in inpatient utilization, decreased incarceration for individuals with behavioral health needs, and substantial cost savings across the justice and health care systems.