We believe in participatory healthcare.

We believe that health begins with individuals, families and communities, and taking care of health is as much about paying attention to whether there are safe places for us to walk, affordable fresh fruits and vegetables available to buy, and ready access to hospitals and doctors. We believe that too often people have been disconnected and disempowered in relation to ownership of our health by a condescending healthcare system, ignoring our values and lifestyles, and medicalizing the most basic steps in caring for ourselves and our loved ones. We all need to become active participants in designing our own care – and re-designing the system as a whole.

To change that, we start with the basics. We design our system and processes with patients and families at the center, and that’s not just something we say — we really bring patients and their families in to help us design the right approaches in each community. This collaborative approach permeates everything we do, from designing care plans with individuals to incorporating local community members as lay coaches and health workers.

Our Program:

We begin by working with primary care providers in the community to identify those who are most likely to benefit from our services, generally individuals in the Medicare population with two or more chronic conditions. As a result of our work, most individuals take the next steps toward self-mastery and become action-oriented about their personal health.

Our step-wise approach:

Customized assessments. We provide clinical and psycho-social assessments to ensure we fully understand each person’s health conditions, risks, and motivations.


Care plan and goals development. Our care management nurses, under the guidance of the PCP, identify clinical components of the care plan and meet with each prospective member and the family, to created a comprehensive, collaborative care plan.


Home health monitoring. We provide a suite of home health monitoring devices that enable us to provide daily assessment of health status, and provide interventions appropriate to the person’s conditions.


Integrated and personalized education. We give everyone a tablet to review personal daily biometric readings. We also give the individual custom educational content, the ability to track goals, and video-conferencing capabilities to reach the care team.


Integrated and personalized support. We tailor support to the person’s condition, preferences, and level of personal self-mastery. We match support programs to the person’s technology comfort level and readiness for change. We employ both digital and people-based tools.


In-home visits from our health performance coaches. Our health professionals are trained in motivational interviewing and check in on the person’s mood, progress toward goals, and perspective on community activities.


Regular visits with the care management nurse. Our nurse will coordinate care with the primary care provider, other community workers, and organizations to ensure 360 degree coverage.


We recognize the importance of family members and welcome their participation in the programs.