The CMO’s Care Guidance™ framework is the foundation of our Population Health approach and commitment to whole-person care management.

The goals of this framework are better clinical outcomes and quality care delivered most cost-effectively leveraging a patient-centric, integrated continuum of care. We are able to identify and meet the needs of medically complex patients who also are burdened by the social determinants of health (SDOH) such as housing, transportation, nutrition. To the extent possible, we strive for enabling successful self-management and thriving in the community for our patients.

Care Guidance™ Process Life Cycle

A structured and personalized care management approach to identify, engage, stabilize and effectively monitor individuals

Care Guidance Process

The Care Guidance™ Life Cycle is designed to proactively identify, engage, stabilize and effectively monitor patients through a comprehensive set of workflows. Central to this framework is a structured care plan that is personalized to address the unique medical, behavioral and social needs of each individual.

Care Guidance™ Core Operational Foundation

A program foundation for transitioning through the care management life cycle

Emergency Department (ED) Triage

  • Transition potential hospital admissions to appropriate care settings.
  • Reduce admissions to the ED.

Care Transitions

  • Identify population at risk for ED visits, readmissions.
  • Ensure that a patient has a PCP and appropriate community support in place.

Intensive Care Management

  • Monitor progress, identify barriers, goals and interventions to prevent admissions.
  • Keep the patient in an appropriate level of care and in a community-based setting.

Our core programs encompass a portfolio of episodic and longitudinal interventions through acute care, ED and community settings. Our program foundation is architected to prevent medically unnecessary inpatient and ED utilization while engaging patients appropriately through the use of key selection criteria.

Coordinated Care Enablement Via the CMO

A centralized care management hub to proactively coordinate across a diverse continuum of medical and social services provider settings

Clinical Delivery Network
Community Based organizations

Our goal is to end cycles of acute care utilization by better leveraging support offered in community and ambulatory settings. The CMO facilitates improved care coordination through setting-specific activities among hub- and community-based social services resources.