Spiras Health, headquartered in Brentwood, TN, provides longitudinal care services to complex, chronically ill patients, specifically COPD and CHF. The Spiras Health approach combines home-based services, telehealth, 2-way digital communications, and remote monitoring. This multi-modal approach allows the patient access to care, regardless of situational complexities, in the mode that suits their preferences, needs, and risk. This also provides ongoing data, from a multitude of sources, to Spiras Health for accurate and efficient interventions. Spiras Health creates value to patients by improving quality of life and to health system/payor partners by reducing total cost of care by addressing avoidable costs and supporting quality metrics. Spiras Health utilizes/provides: 1. Multi-disciplinary team approach consisting of MDs, NPs, RRTs, RNs and community resources 2. Predictive modeling and machine learning to identify patients at highest risk for avoidable costs 3. Patient activation strategy for ongoing engagement, goal setting, treatment plan adherence, and behavior modification 4. Multi-modal approach to care delivery 5. Provider collaboration process to partner with patient's PCP and specialists, bridging care from physician office to home 6. Improved clinical and financial outcomes