Provides comprehensive care management from a single lead care manager. Coordinates all health-related care. Includes coordination for physical health, mental health, dental care, and social services.

Serves the Following Adult Populations of Focus:

At Risk for Avoidable Hospitalization or ED use

Birth Equity

Experiencing Homelessness

Living in the Community and at Risk for LTC Institutionalization

Nursing Facility Residents Transitioning to the Community

Serious Mental Health and or SUD Needs

Serves the following Youth Population of Focus:

At Risk for Avoidable Hospitalization or ED use

Experiencing Homelessness-Homeless Families Or Unaccompanied Children and Youth

Serious Mental Health and or SUD Needs (includes children with high ACEs scores)