Programs Targeting Complex Patients — An Inventory

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

Click on the state names below to see the programs in that state.

Multistate Initiatives

Accountable Health Communities Model
Anthem Foundation and Feeding America's Food is Medicine Initiative
Camden Coalition of Healthcare Providers
Care Management Plus
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 

District of Columbia

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


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

New Jersey

Camden Coalition of Healthcare Providers

New Mexico

Hidalgo Medical Services
La Cosecha

New York

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"

North Dakota

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

Puerto Rico

NEEDS Educational Foundation's Innovative Healthcare High-Utilizers Program

Rhode Island

Homeless-Oriented Primary Care Clinic

South Carolina

AccessHealth Spartanburg


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