Human-first care coordination for the members health plans can’t reach
Where the borders are
The bus stop
Care gaps open in ordinary places: a bus stop, a pharmacy counter, a front porch, a market aisle. Our local Care Coordinators meet Medicare Advantage, Medicaid, D‑SNP, Exchange and Veteran members in those places, and stay with them until the need is met.
No ride usually means no appointment. So the first call is often about getting there, and the visit gets booked once the ride is set.
PHARMACY
The pharmacy
Prescriptions picked up, and taken
Medication adherence moves Star Ratings one refill at a time. Coordinators work from pharmacy data, call when a statin or blood-pressure refill goes quiet, and sort out what is in the way: the cost, the ride, the side effect nobody mentioned.
The front porch
One conversation for the whole household
Members live in families, so we reach them that way. ConnectAllCare links the people in a household, and a single outreach can settle a child’s checkup, a mother’s mammogram and a grandfather’s eye exam. Spanish-speaking coordinators call the households that prefer Spanish.
MARKET
The market
Food, diapers, housing, a ride
A member worried about groceries or rent will not put a colorectal screening first, and nobody should expect them to. We connect the social needs that sit in front of the medical one, and document them for the plan along the way.
The need met
Screened, closed, confirmed
We stay until the screening is completed, the result is confirmed and the next step is booked. That is the only kind of engagement we count.
What every outreach rests on
The human touch
Locally based Care Coordinators, not a call center. People who know the neighborhoods they call, including Spanish-speaking coordinators, and who earn a member’s trust before asking for anything.
Technology that amplifies
ConnectAllCare puts the household, the verified phone number and the open gaps in front of the coordinator, so the time goes into the conversation instead of the search.
Outcomes that are real
We count completed actions: the screening done, the prescription filled, the result confirmed. A dialed number or a voicemail is not engagement.
One coordinator, four steps
The same person carries a member from the first hello to the confirmed result.
1
Engage and activate
Find the member on a number that works and earn the first yes, often through a family member they trust.
2
Address social needs
Rides, food, diapers, housing: the needs that block care get handled first.
3
Close gaps in care
Screenings, refills and provider visits, booked, reminded and kept.
4
Track results
Every interaction logged in ConnectAllCare, followed up until the result is confirmed.
Each figure is one plan’s published result, shown with its plan type. None is an average across plans, and none is a guarantee.
A representative member journey
Two screenings, one morning
Challenge
A Spanish-speaking member living with diabetes had missed her eye exam two years running. Automated reminders in English went unanswered, and the clinic was two bus transfers away.
Action
A Spanish-speaking Care Coordinator reached her through her son, booked the retinal exam and an overdue mammogram for the same morning, and arranged the ride.
Impact
Both screenings were completed. The coordinator confirmed the results reached her primary care doctor and set the follow-up visit.
A composite drawn from common situations. Not a real member, and no real details.
Named one of Modern Healthcare’s Best Places to Work in Healthcare for 2026.
The work depends on the people who make the calls, so how we treat them matters.
Bring us the members you have not been able to reach
Tell us which measures you are chasing, which populations are hardest to reach and what you need to show by the next reporting cycle. We will tell you plainly where human outreach can move them.
