MHN Model of Care

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.