A relatively small number of patients with complex medical, social, and behavioral needs account for a large proportion of healthcare spending. To address this, a variety of programs have been developed that target high-need high-cost individuals with models of care specifically tailored to their needs. The following inventory contains profiles of nearly a hundred programs across 36 states and territories. To qualify for inclusion, programs must specifically target complex patients and go beyond medical care coordination to offer either a level of social services integration or a program that specifically addresses socioeconomic disparities. Programs or models operating in multiple states are listed under "Multistate."
Also see the Hub's Easy Explainer describing this project, a Research Brief, Addressing the Unmet Medical and Social Needs of Complex Patients, and our comprehensive resources page.
This listing of programs is a work in progress. If you know of a program that should be added, or have suggested changes to a program description, please let us know! You can send your suggestions to HubInfo@altarum.org.
Click on the state names below to see the programs in that state.
Accountable Health Communities Model
Anthem Foundation and Feeding America's Food is Medicine Initiative
Camden Coalition of Healthcare Providers
Care Management Plus
CareMore
Cigna Collaborative Care Program
Collaborative Initiative to Help End Chronic Homelessness
Community Aging in Place, Advancing Better Health for Elders (CAPABLE)
Community Care Teams
Geriatric Resources for Assessment and Care of Elders (GRACE)
Guided Care
Health Leads
Homeless Patient-Aligned Care Teams
Housing First
Housing Plus Services
Independence at Home
Maximizing Independence at Home
Medical-Legal Partnerships
Mobile Integrated Health/Community Paramedicine programs
Nurse-Family Partnership
Program of All-Inclusive Care for the Elderly (PACE)
Project ECHO
Safety Net Medical Home Initiative
Transforming Complex Care
Trinity Health System's Complex Care Model
Wellcare Community Impact Model
Alaska Medicaid Coordinated Care Initiative
Southcentral Foundation / Nuka System of Care
Mercy Maricopa Integrated Care
Maricopa Crisis Response Network
Verde Valley Caregiver's Coalition's Transitional Care Program
10th Decile Project
Alameda Health System
AC Care Connect
Alliance for Leadership and Education's Community Based Health Home
Fresh Approach's VeggieRx Program
Los Angeles Department of Health Services’ Care Connections Program
Multicultural Health Foundation's Patient Health Improvement Initiative (San Diego)
San Francisco Health Network’s Complex Care Management Program
Redwood Community Health Coalition's Complex Care Initiative
San Diego 2-1-1's Community Information Exchange
Sutter Health's ED Enhanced Case Management Program
Denver Health Medical Plan's Targeted Case Management
Metro Community Provider Network's Bridges to Care Program
Hunger Free Colorado
Northern Colorado Health Alliance Regional Care Collaborative Organization
Saint Francis Hospital and Medical Center's Women's Health Center
Christiana Care Medical Home Without Walls
Medical House Call Program at MedStar
My Health GPS
Bob Janes Triage Center & Low Demand Shelter
UF Health's Care One Clinic
Mercy Care's Street Medicine Program
St. Luke's Hospital's ED Consistent Care Plan
University of Illinois' Emergency Patient Interdisciplinary Care Project (Chicago)
KanCare Behavioral Health Homes
University Hospital's Population Health Management Complex Case Program
Catholic Charities Health Guardians
MaineCare Health Homes and Community Care Teams
Access Health at Sinai Hospital
Healthy Howard's Community Based Care Team
Medical House Call Program at MedStar
Community Hospital Acceleration, Revitalization, & Transformation (CHART) Investment Program
Greater Lawrence Family Health Center
Greater Boston Super-Utilizer Project
Innovative Stable Housing Initiative
Massachusetts General Hospital's Home Base Program
OneCare
Eastern Market Farm Stand/Community Health & Social Services Center's Fresh Prescription Program
Genesys HealthWorks
Spectrum Health's Center for Integrative Medicine
Washtenaw County Health Department's Prescription for Health Program
Hennepin Health
Courage Kenny Advanced Primary Care Clinic
Show Me Healthy Housing
Truman Medical Centers Super-Utilizer Project
Mountain Pacific Quality Health's ReSource Teams
Camden Coalition of Healthcare Providers
Hidalgo Medical Services
La Cosecha
Healthy Alliance Independence Practice Association
Medicaid Health Homes
Medicaid Redesign Team (MRT) Waiver
Montefiore Medical Center's Healthy Store Initiative
New York Department of Health and Mental Hygiene's "Health Bucks"
Northland Healthcare Alliance's Care Coordination for Seniors
Better Health Partnership’s Red Carpet Care
Cincinnati Super-Utilizer Pilot Project
Health Collaborative’s ED Care Coordination Pathway
MetroHealth's Institute for H.O.P.E.
University Hospital's Rainbow Connect Program
CareOregon's Community Care Program
Oregon Health Plan
Gorge Grown Food Network's Veggie Rx Program
Project Access NOW's C3 Community Assistance Program
Community Care Behavioral Health Organization
Geisinger Health's Fresh Food Farmacy
Lancaster General Health's Care Connections
Lehigh Valley Super Utilizer Partnership
PinnacleHealth's Community Health Navigation Networks
South Central PA High-Utilizer Learning Collaborative
WellSpan Health's Bridges to Health
NEEDS Educational Foundation's Innovative Healthcare High-Utilizers Program
Homeless-Oriented Primary Care Clinic
Regional One Health's ONE Health Initiative
Brazos Valley Care Coordination Program
Center for Health Care Services' High-Utilizer/Integrated Care Program (San Antonio)
Patient Care Intervention Center
Integrated Communities Care Management Model
OneCare Vermont
Vermont Blueprint for Health Chronic Care Initiative
Support and Services at Home
Virginia Commonwealth University Medical Center's Complex Care Clinic
Health Homes
King County Healthy Homes Project
Whatcom Alliance for Health Advancement
Foundational Community Supports
ThedaCare's Internal Medicine Clinic & Community Paramedicine Program