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Our Approach

Our innovative care management strategy centers on the primary care component of health care. It is critical that primary care providers are connected seamlessly with all network providers, each with access to the tools and resources they need to provide the right care, at the right time, in the right place.

This connection allows providers to make well-informed clinical decisions. We touch every aspect of our patients’ health by maximizing their experience with providers at all levels of care, and focusing attention on optimizing health, versus illness and disease.

Multidisciplinary Team

Alongside your provider, our local multidisciplinary clinical team members engage, educate and assist patients using population health management strategies. Our registered nurse (RN) care coordinators provide elevated attention to detail to high risk patients with chronic illnesses. Our social worker (SW) care coordinators are there to support patient needs such as support for housing, transportation or medications. The clinical pharmacists provide a wide-range of services inclusing investigating lower cost options to increase medication adhererence. Our ambulatory care coordination assistants facilitate care after patients have been discharged from the hospital. 

Population Health Management

Our proactive application of strategies and interventions to defined groups of individuals across the continuum of care improves the health of those individuals at the lowest necessary cost. Throughout the care journey we improve access to care, assist with coordination of patient transfers between care environments, manage 90-day episodes of care, reduce hospital readmission rates, and collaborate with the providers and practices to identify and schedule needed prevention screenings.