Start: September 2019

Funder: Robert Wood Johnson Foundation


To improve health outcomes and foster health equity for individuals with complex needs, health care systems are increasingly pursuing person-centered approaches for delivering medical, behavioral health, and social services. As a result, many health systems have implemented distinct strategies to improve care for this population, including: (1) complex care management; (2) trauma-informed care; (3) physical and behavioral health integration; and/or (4) mechanisms to address health-related social needs. Few systems, however, have adopted all of these strategies, and even fewer have effectively aligned these efforts, either internally or externally with community partners.

Advancing Integrated Models (AIM), led by the Center for Health Care Strategies and made possible through support from the Robert Wood Johnson Foundation, is a national multi-site demonstration assisting health systems and community providers in integrating innovative, “next-generation” person-centered approaches for individuals with complex health and social needs. Over two years, AIM is supporting efforts to:

  • Integrate key strategies – complex care management, trauma-informed care, physical and behavioral health integration, and/or mechanisms to address health-related social needs – into existing care models for people with complex health and social needs;
  • Partner with state Medicaid agencies or local managed care organizations to identify innovative approaches to supporting integrated models of care; and
  • Engage with patients and community members to design integrated care models that meet the unique needs of the individuals served.

AIM includes eight competitively selected pilot sites, representing innovators in care for both pediatric and adult populations. Each of the sites is collaborating with a state Medicaid or health plan partner to implement sustainable strategies for enhancing or expanding person-centered care designed and delivered with input from the individuals and communities being served. The pilot sites are as follows:

  • Bread for the City, Washington D.C. Piloting a “food home” model through collaboration between social services, care management, medical, and food teams to reduce food insecurity and improve overall health outcomes.
  • Center for the Urban Child and Healthy Family at Boston Medical Center, Boston, MA. Creating the Pediatric Practice of the Future by empowering families to define their health priorities and design their own care, and re-imagining community partnerships to address health-related social needs.
  • Denver Health, Denver, CO. Expanding and adapting the Ryan White model of HIV care for other high-risk groups with complex health and social needs, including justice-involved and homeless populations.
  • Hill Country Health and Wellness Center, Round Mountain and Redding, CA. Integrating substance use disorder treatment into primary care teams, aligning unique complex care models to create a seamless continuum of care, and expanding access to care to people who currently do not qualify for complex care management.
  • Johns Hopkins HealthCare, Baltimore, MD. Improving care for mothers experiencing post-partum depression, children with asthma, and children with sickle-cell disease through the integration of behavioral health services, social supports, and community health workers.
  • Maimonides Medical Center, Brooklyn, NY. Uniting disparately funded programs, creating a “single point of entry,” and developing a centralized navigation resource for patients, families, and providers to increase access to care management for individuals with complex health and social needs.
  • OneCare Vermont, Vermont. Integrating social needs data into a statewide care coordination platform to inform care management activities and increase collaboration among health and human services providers and alignment across sectors.
  • Stephen and Sandra Sheller 11th Street Family Health Services, Philadelphia, PA. Expanding behavioral health and trauma-informed care services to include acknowledgment of the impact of racism, and develop race-conscious programming to improve patient engagement across medical, behavioral, and dental departments.

Each of these pilot sites will receive tailored, expert technical assistance, access to national subject matter experts, and participate in a peer learning collaborative to accelerate solutions across sites. CHCS will distill lessons and share best practices nationally to support other health care organizations seeking to adopt more integrated care models for individuals with complex needs.