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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 HubInfo@altarum.org.

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


Multistate Initiatives

Accountable Health Communities Model
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

Alaska Medicaid Coordinated Care Initiative
Southcentral Foundation / Nuka System of Care

Arizona

Mercy Maricopa Integrated Care 
Maricopa Crisis Response Network 
Verde Valley Caregiver's Coalition's Transitional Care Program

California

10th Decile Project
Alameda Health System
AC Care Connect
Alliance for Leadership and Education's Community Based Health Home
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

Colorado

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

Connecticut

Saint Francis Hospital and Medical Center's Women's Health Center

Delaware

Christiana Care Medical Home Without Walls 

District of Columbia

Medical House Call Program at MedStar
My Health GPS

Florida

Bob Janes Triage Center & Low Demand Shelter 
UF Health's Care One Clinic 

Iowa

St. Luke's Hospital's ED Consistent Care Plan

Illinois

University of Illinois' Emergency Patient Interdisciplinary Care Project (Chicago) 

Kansas

KanCare Behavioral Health Homes

Kentucky

University Hospital's Population Health Management Complex Case Program

Louisiana

Catholic Charities Health Guardians

Maine

MaineCare Health Homes and Community Care Teams

Maryland

Access Health at Sinai Hospital
Healthy Howard's Community Based Care Team
Medical House Call Program at MedStar

Massachusetts

Community Hospital Acceleration, Revitalization, & Transformation (CHART) Investment Program
Greater Lawrence Family Health Center 
Greater Boston Super-Utilizer Project
Massachusetts General Hospital's Home Base Program
OneCare

Michigan

Genesys HealthWorks
Spectrum Health's Center for Integrative Medicine

Minnesota

Hennepin Health
Courage Kenny Advanced Primary Care Clinic

Missouri

Show Me Healthy Housing
Truman Medical Centers Super-Utilizer Project

Montana

Mountain Pacific Quality Health's ReSource Teams

New Jersey

Camden Coalition of Healthcare Providers

New Mexico

Hidalgo Medical Services
La Cosecha

New York

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

Ohio

Better Health Partnership’s Red Carpet Care
Health Collaborative’s ED Care Coordination Pathway

Cincinnati Super-Utilizer Pilot Project

Oregon

CareOregon's Community Care Program
Oregon Health Plan
Gorge Grown Food Network's Veggie Rx Program
Project Access NOW's C3 Community Assistance Program

Pennsylvania

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

Texas

Brazos Valley Care Coordination Program
Center for Health Care Services' High-Utilizer/Integrated Care Program (San Antonio)
Patient Care Intervention Center

Vermont

Integrated Communities Care Management Model
OneCare Vermont
Vermont Blueprint for Health Chronic Care Initiative
Support and Services at Home

Virginia

Virginia Commonwealth University Medical Center's Complex Care Clinic 

Washington

Health Homes 
King County Healthy Homes Project
Whatcom Alliance for Health Advancement
Foundational Community Supports

Wisconsin

ThedaCare's Internal Medicine Clinic & Community Paramedicine Program