• Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis • Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies • Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made • Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc. • Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions. • Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.

• Run monthly clinical calls with chronic care patients • Drive behavior change through coaching and education • Maintain precise, compliant documentation using our platform • Close preventive care gaps and coordinate services • Update care plans and track interventions • Support transitions of care to reduce readmissions • Manage your panel efficiently and consistently

• Manage a large 100+ panel of Medicare patients with chronic conditions • Run monthly clinical calls with chronic care patients • Drive behavior change through coaching and education • Maintain precise, compliant documentation using our platform • Close preventive care gaps and coordinate services • Update care plans and track interventions • Support transitions of care to reduce readmissions • Manage your panel efficiently and consistently

• Utilize our specialized care management software to call a full caseload of Medicare patients with two or more chronic conditions on a monthly basis • Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies • Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made • Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc. • Conduct Transitional Care Management activities to high-risk patients discharged from the hospital and reduce unnecessary readmissions • Close care gaps by encouraging preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up appointments, etc.