Services

Practice Transformation Support

Implementation of value-based care models
Workflow redesign for efficiency and quality
Training on care coordination and population health management
Regulatory compliance guidance and reporting

Care Management Services

Deployment of interdisciplinary care teams (nurses, social workers, care managers, etc.)
High-risk patient outreach and engagement
Chronic disease management and goal setting
Implement or refine transitions in care
Behavioral health integration and care planning

Data Analytics & Reporting

Clinical Quality Measure (CQM) tracking and improvement
Utilization and cost trend analysis
Patient stratification and risk scoring
Dashboard development and performance monitoring

Patient Engagement & Preventive Care

Annual Wellness Visit (AWV) coordination
Health Risk Assessments (HRAs)
Preventive screening reminders and gap closure
Patient education and coaching (including motivational interviewing techniques)

Strategic Program Consultation

Guidance on participation in state, federal and commercial payer models and initiatives
Support with incentive alignment and shared savings models within Accountable Care Organizations
Assistance for FQHCs and independent practices in navigating federal/state-funded care programs

Community Resource Integration

Linking practices with social service organizations
Addressing social determinants of health (SDOH)
Building care partnerships across sectors for wraparound support