Solutions

Chronic Condition Health Coaching

Our dedicated health coaches work closely with higher-risk patients for 2-3 months, both virtually and in person, to deliver personalized coaching and care navigation in collaboration with our Nurse Practitioners.

Focusing on diabetes, hypertension, asthma, COPD, and CHF, our coaches use motivational interviewing to help patients set and achieve realistic goals, adhere to medications, and stay on track with their care plans. We reinforce your clinical guidance and share timely updates back to your team.

Behavioral Health Coaching & Support

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Collaborative Care Model

We expand access to behavioral health support by following the Collaborative Care Model, which is rooted in over 20 years of evidence-based medicine.

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Behavioral Health Coaches

Our behavioral health coaches assess patient needs, provide brief counseling interventions, and conduct weekly case reviews with a consulting psychiatrist.

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Clinical Updates & Collaboration

We keep you informed of updates to the patient’s clinical status and medication recommendations, ensuring behavioral health is integrated seamlessly into the broader care plan.

Clinical Quality Support

Our Health Center Liaisons meet with health centers monthly to review open quality gaps and provide workflow support. We help ensure patients stay up to date on preventive services like wellness exams, cancer screenings, and vaccinations, and that chronic conditions are effectively managed—ultimately driving stronger quality performance and outcomes.