Why invest in redesigning care for people with complex needs?
51 Resources
State Map
Use the filters below to locate, learn about, and connect with complex care programs based on categories such as target population, care model, and other important features. Multiple category characteristics can be selected. These programs were identified by the Center for Health Care Strategies. The Playbook welcomes submissions from the field; learn how to submit your program to the Playbook.
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AccessHealth Spartanburg
AccessHealth Spartanburg
Spartanburg, SC
Target Population:
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- People with Advanced Illness
Insurance:
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites:
AccessHealth Spartanburg has not been replicated.
Outcome Notes:
A formal evaluation is currently being conducted.
Point of Contact:
Carey Rothschild, Director
864-560-0198
crothschild@srhs.com
Complex Care
Alameda Health System
Hayward, CA
Target 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:
Alameda Health System's Complex Care program operates in two locations in Northern California (Oakland, CA, and Hayward, CA).
Outcome Notes:
None yet
Point of Contact:
David Moskowitz, Medical Director
510-437-4408
dmoskowitz@alamedahealthsystem.org
Complex Care
Alameda Health System
Oakland, CA
Target 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:
Alameda Health System's Complex Care program operates in two locations in Northern California (Oakland, CA, and Hayward, CA).
Outcome Notes:
None yet
Point of Contact:
David Moskowitz, Medical Director
510-437-4408
dmoskowitz@alamedahealthsystem.org
The Community Integrated Healthcare Partnership
Better Health East Bay Foundation
Berkeley, CA
Target Population:
- People with Multiple Chronic Conditions
Insurance:
- 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 Community Integrated Healthcare Partnership operates in two locations in the East Bay of California (Berkeley, CA; and Oakland, CA).
Outcome Notes:
No formal evaluation yet conducted.
Point of Contact:
James H Hickman, CEO, Better Health East Bay Foundation
415-990-8239
jim@hickmanstrategies.com
The Community Integrated Healthcare Partnership
Better Health East Bay Foundation
Oakland, CA
Target Population:
- People with Multiple Chronic Conditions
Insurance:
- 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 Community Integrated Healthcare Partnership operates in two locations in the East Bay of California (Berkeley, CA; and Oakland, CA).
Outcome Notes:
No formal evaluation yet conducted.
Point of Contact:
James H Hickman, CEO, Better Health East Bay Foundation
415-990-8239
jim@hickmanstrategies.com
Camden Coalition Care Management Initiatives (CMI)
Camden Coalition of Healthcare Providers
Camden, NJ
Target Population:
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
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 Camden Coalition's Care Management Initiatives program has not been replicated.
Outcome Notes:
A randomized-control trial is underway at the Camden Coalition.
Point of Contact:
Kelly Craig, Chief Strategy and Information Officer
856-365-9510
kelly@camdenhealth.org
CareMore
CareMore
Atlanta, GA
Target Population:
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Advanced Illness
Insurance:
- Medicare
- Medicaid
- Medicare / Medicaid
Quality of Evidence:
Promising
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:
CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes:
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact:
Sachin Jain, President/CEO
617-901-7000
sachin.jain@caremore.com
CareMore
CareMore
Des Moines, IA
Target Population:
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Advanced Illness
Insurance:
- Medicare
- Medicaid
- Medicare / Medicaid
Quality of Evidence:
Promising
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:
CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes:
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact:
Sachin Jain, President/CEO
617-901-7000
sachin.jain@caremore.com
CareMore
CareMore
Green Valley, AZ
Target Population:
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Advanced Illness
Insurance:
- Medicare
- Medicaid
- Medicare / Medicaid
Quality of Evidence:
Promising
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:
CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes:
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact:
Sachin Jain, President/CEO
617-901-7000
sachin.jain@caremore.com
CareMore
CareMore
Henderson, NV
Target Population:
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Advanced Illness
Insurance:
- Medicare
- Medicaid
- Medicare / Medicaid
Quality of Evidence:
Promising
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:
CareMore is replicated at fifty-six sites across the country, including forty in California.
Outcome Notes:
A case study examining results found: decreased inpatient admissions and length of stay for those enrollees admitted; and decreased all-cause readmissions; and decreased skilled nursing facility admissions and length of stay.
Point of Contact:
Sachin Jain, President/CEO
617-901-7000
sachin.jain@caremore.com
Key Questions
Find curated resources about promising approaches to improving care for people with complex needs.
Who are people with complex needs?
41 Resources
What care models are promising?
83 Resources
What practical tools can I use to redesign care?
17 Practical Plays