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:
AccessHealth Spartanburg
AccessHealth SpartanburgSpartanburg, SCTarget Population: - Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- People with Serious 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, Director864-560-0198crothschild@srhs.com
Complex Care
Alameda Health SystemHayward, CATarget 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 Director510-437-4408dmoskowitz@alamedahealthsystem.org
Complex Care
Alameda Health SystemOakland, CATarget 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 Director510-437-4408dmoskowitz@alamedahealthsystem.org
The Community Integrated Healthcare Partnership
Better Health East Bay FoundationBerkeley, CATarget 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 Foundation415-990-8239jim@hickmanstrategies.com
The Community Integrated Healthcare Partnership
Better Health East Bay FoundationOakland, CATarget 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 Foundation415-990-8239jim@hickmanstrategies.com
Camden Coalition Care Management Initiatives (CMI)
Camden Coalition of Healthcare ProvidersCamden, NJTarget 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 Officer856-365-9510kelly@camdenhealth.org
CareMore
CareMoreAtlanta, GATarget 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
- 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/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreDes Moines, IATarget 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
- 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/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreGreen Valley, AZTarget 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
- 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/CEO617-901-7000sachin.jain@caremore.com
CareMore
CareMoreHenderson, NVTarget 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
- 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/CEO617-901-7000sachin.jain@caremore.com
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:
AccessHealth Spartanburg
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
AccessHealth Spartanburg has not been replicated.
A formal evaluation is currently being conducted.
Complex Care
- People with Multiple Chronic Conditions
- 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
Alameda Health System's Complex Care program operates in two locations in Northern California (Oakland, CA, and Hayward, CA).
None yet
Complex Care
- People with Multiple Chronic Conditions
- 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
Alameda Health System's Complex Care program operates in two locations in Northern California (Oakland, CA, and Hayward, CA).
None yet
The Community Integrated Healthcare Partnership
- People with Multiple Chronic Conditions
- 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
The Community Integrated Healthcare Partnership operates in two locations in the East Bay of California (Berkeley, CA; and Oakland, CA).
No formal evaluation yet conducted.
The Community Integrated Healthcare Partnership
- People with Multiple Chronic Conditions
- 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
The Community Integrated Healthcare Partnership operates in two locations in the East Bay of California (Berkeley, CA; and Oakland, CA).
No formal evaluation yet conducted.
Camden Coalition Care Management Initiatives (CMI)
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- 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 Camden Coalition's Care Management Initiatives program has not been replicated.
A randomized-control trial is underway at the Camden Coalition.
CareMore
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
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.
CareMore
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
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.
CareMore
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
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.
CareMore
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
CareMore is replicated at fifty-six sites across the country, including forty in California.
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.
