Our Care Management Model

The members we see typically face barriers to healthcare: housing and food insecurity, substance use challenges, and behavioral health and complex chronic health conditions.

Our focus is whole-person care, restoring our members’ total health and wellbeing.

Our Transformational Trio

Taken individually, these are just three simple steps. But put them together, and they are our recipe for healthcare transformation. We work with our health plan partners to fulfill our vision: health restored to all our vulnerable and chronically ill neighbors.



Our cutting-edge, proprietary algorithm leverages statistical methods of artificial intelligence to match our care model to the members most suited for it. Our members are vulnerable and chronically ill and spend the most healthcare dollars.


Using our team-based approach, we spend time to hear members’ stories and build trust, whether we are the PCP or partner with existing network PCPs.


We set members on a vastly improved health and life trajectory with custom care plans that address medical and behavioral health and SDoH needs to improve outcomes and reduce cost.

A New System of Care

Members, providers, and payers all feel the sting of a healthcare system that is not designed to serve those who need it most. Our model focuses on the highest needs populations, where our interdisciplinary approach have the most impact. That’s what makes the most economical—and compassionate—sense.


Medical Economics

Results That Drive Us

In over two decades, we have radically transformed the communities we serve by focusing on the quality of each member’s life. The proof it works: a reduction in costly, facility-based care; an increase in quality outcomes; and happier, healthier members of the community.


Data Drivers