The MHN model of care moves care management to the primary care practice and empowers care managers to work closely with patients to prevent readmissions and improve outcomes. The model creates a structured approach to care management by providing the appropriate tools, processes, staffing and sharing of care plans. Dedicated care teams coordinate their efforts across settings to ensure that healthcare delivery is appropriate and timely. Innovative technology allows the care team to use a collaborative, team-based approach to care by tracking patients across the health care continuum. In addition, care management at the primary care level help prioritize care coordination, support timely interventions and streamline care transitions. The process starts with an innovative screening tool, MHN's health risk assessment, which incorporates medical, behavioral and social factors and promotes whole-person care. This comprehensive approach stratifies patient health risk into high, medium or low risk cohorts, and enables providers to prioritize care, directing resources to the patients that need them the most.

Medical Home Network (MHN) is a not-for-profit collaborative that has fundamentally changed how care is delivered. Our proven model of care unites provider communities and diverse healthcare entities around a common goal: to redesign healthcare delivery and transform the way care is managed at the practice level. It starts with providers and patients working together to improve health. Care teams drive engagement by developing relationships with patients that extend beyond the four walls of the primary care practice. We provide the tools and processes to help care teams engage patients and help them become an accountable member of the team. Research shows that patients who are involved in making their healthcare decisions tend to be healthier and have better outcomes. By connecting providers and delivering real-time information, we enable coordinated care management, improve transitions of care, and promote timely follow-up. But the most important change is that patients receive better care where and when they need it.