Our Model Of Work
We understand that the health care system is complex and many, especially the most high-need and medically complex patients, need a whole-person approach to care management.
Through a peer-driven, personalized, comprehensive care management approach, we address social determinants of health and reduce health disparities by connecting people to health coverage, primary care, mental and behavioral health care, housing, and other critical resources. We walk with our clients as they navigate the continuum of care and stand with them until they reach stability.
Our programs help clients achieve their overall health goals by delivering services that:
- Improve quality outcomes.
- Reduce health disparities.
- Drive delivery system transformation and innovation through value-based initiatives.
- Modernize systems and payment reforms to improve the lives of our clients and all those served through the healthcare system.
We provide intensive outreach and care coordination for people experiencing homelessness and/or have complex health and behavioral health issues. Our services include:
- Addressing social determinants of health / Mitigating barriers
- Linkage to insurance coverage, eligible programs and services
- Facilitating connections & transitions between hospitals & community (Primary Care provider)
- Linkage to full housing continuum
- Co-management of clients with health & housing partners
- Functional assessment & clinical oversight
Our population health data infrastructure supports our work to track the care and outcomes of our clients. This allows for data mining and analysis, reducing complexity and increasing flexibility to promote consistent and seamless data-sharing.
- Outcome focused
- Track, manage and report on all services provided
- Full integration of all our programs
- Quickly adapt care plans to meet immediate and long-term needs
- Coordinate with other agencies to address client health and social needs
- Reduce duplication of services
- See the entire lifetime of a client's health journey