REACH THE MEMBERS DRIVING YOUR SPEND
Care Management That Travels to the Member
Your highest-cost members aren’t in your care management program. They’re in the emergency department. Care at Home Solution reaches the multi-chronic, high-utilizing members most plans can’t engage — with Providers, RN care managers, social workers, and community health workers hired from the communities they serve.
THE ENGAGEMENT GAP
You Already Have Care Management.
That’s Not the Gap.
Health plans don’t lose ground on high-cost members for lack of a program — they lose it on reach. Care management works for members who answer the phone, attend appointments, and respond to outreach. The members driving your spend do none of those things. They’re homebound, without transportation, managing behavioral health needs, or carrying a history with the health system that taught them not to pick up. They aren’t non-compliant. They’re unreachable by a model built on remote outreach. Closing that gap delivers:
- Fewer avoidable admissions and ED visits among the members generating the most utilization
- Successful transitions of care, closing the post-discharge window where readmissions originate
- HEDIS and Star measure closure for members who never present to care
- Risk score accuracy for members whose conditions go undocumented because no one sees them
- A clearer line of sight into the social and behavioral barriers driving avoidable cost
WHAT WE DELIVER
Three Programs. One Field Team.
Care at Home Solution runs alongside your existing care management program rather than replacing it, taking the members your current team can’t reach. Each program is delivered by the same community-based workforce, so members experience one relationship rather than a series of handoffs.
Intensive Care and Home-Based Management
Keeps your highest-risk members stable at home.
- Ongoing in-home clinical management for multi-chronic, high-utilizing members
- Medication reconciliation and adherence support for polypharmacy members
- Direct navigation of social barriers — housing, transportation, food, benefits
- Integrated behavioral health and medical support rather than parallel programs
- PCP updates
Transitions of Care
Prevents the readmissions phone-based programs miss.
- In-person post-discharge follow-up inside the window when readmissions originate
- Medication verification and reconciliation at home, not by phone
- Follow-up appointment scheduling, reminders, and transportation
- Escalation to clinical staff before a crisis becomes an admission
- Handoff of critical information with the primary care team
Quality and Preventive Care
Closes gaps for members who never present.
- HEDIS and Star measure gap closure in the home
- Annual wellness visits for members who don’t attend appointments
- Chronic condition screening and monitoring
- Documentation that supports risk score accuracy
OUR MODEL
A Phone Call Is an Invitation.
A Person at the Door Is a Relationship.
Care at Home Solution fields a community-based workforce hired from the neighborhoods it serves — multilingual, in person, and trained to work with members who have stopped engaging with the health system entirely. They knock. They come back. They stay long enough to find out what’s actually preventing the member from getting care. That’s the part you can’t build out of a caseload reassignment.
Hired Locally
Field staff come from the communities they serve, with the language alignment and lived experience that make a first visit possible.
Trained for Complexity
Behavioral health, de-escalation, and chronic disease management, supervised by licensed clinical staff.
Integrated, Not Parallel
Workflows connect to your care management team and sit on the same data layer, so nothing falls between vendors.
Client Results
What Changes When Unreachable Members
Become Reachable
Results from our partnership with Great Lakes Integrated Network, across 315 members enrolled a minimum of 10 days and measured over a three-month period.
WHERE TO START
Start With a Population, Not a Delegation
Most plans begin with a defined population and a fixed measurement window rather than a full delegation. A pilot scoped to a single region, product line, or risk tier gives you your own numbers before a broader contracting conversation.
01 — Scope the Population
One region, product line, or risk tier. We agree the cohort and the measurement window up front.
02 — Build the Local Team
RNs, social workers, and community health workers hired from the neighborhoods being served.
03 — Measure Against Your Own Data
Your numbers, your cohort, before any broader contracting conversation.
POWERED BY ARC
Field Work, Connected to Everything Else
Care at Home Solution runs on the same platform as the rest of our health plan operation. Field encounters, assessments, and escalations flow into ARC alongside claims, utilization, and quality data — so the work the field team does in the home shows up in your reporting, your risk adjustment, and your quality performance rather than sitting in a separate system.