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:
Priority Care Center
Humboldt IPAEureka, CATarget Population: - People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- 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: Humboldt IPA's Priority Care Center has not been replicated.
Outcome Notes: Early results suggest a reduction of inpatient hospitalizations.
Point of Contact: Jane Brown , Operations Manager 707-442-0478jbrown@humboldtipa.com
Independence at Home
Independence at HomeIrving, TXTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeJacksonville, FLTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeOkemos, MITarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomePhiladelphia, PATarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomePortland, ORTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeRichmond, VATarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeWashington, DCTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeWest Allis, WITarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeWestbury, NYTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes: Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact: Dr. K. Eric De Jonge, Director of Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
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:
Priority Care Center
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- 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
Humboldt IPA's Priority Care Center has not been replicated.
Early results suggest a reduction of inpatient hospitalizations.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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 Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.