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
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- People with Advanced 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 Advanced 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 Advanced 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 Advanced 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 Advanced 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.
