Whitbeck said. “Give them what they need, when they need it, and where they need it and keep them out of the hospital. Once physicians started practicing that way, it changed the culture. Now with us, it’s been the culture for decades.” While the practice initiated case management for early Medicare Advantage risk contracts, it has expanded those roles to accommodate today’s value-based programs. It used Comprehensive Primary Care Initiative funds to set up care coordination and added infrastructure to post-care coordinators at clinic locations. Once high-risk patients are identified through American Academy of Family Physicians (AAFP) guidelines, they are assigned a care coordinator, who reaches out to them at least monthly. One staff member is dedicated to patients who are h

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