CHSGa companies serve members characterized by:

• Medical complexity
• Functional impairment and need for assistance with activities of daily living
• Caregivers with high rates of stress and exhaustion
• Residence in rural counties, many lacking sufficient numbers of primary care and specialty providers, with transportation as an added challenge
• Dual eligibility for Medicare-Medicaid with accompanying health risks from social drivers, including:

  - Access to medical services
  - Economic instability
  - Nutritional insecurity/lack of access to healthy foods
  - Lack of access to safe, adequate housing
  - Poor health literacy
  - Lack of transportation​

Additionally, the CHSGa LTSS patient population faces significant risk of poor health outcomes from multiple factors, compounded by presence/prevalence of significant co-morbidities: 

• Age
• Race/ethnicity with accompany health disparities over a lifetime
• High rates of co-occurring conditions including hypertension, diabetes, Chronic Obstructive Pulmonary Disease (COPD), heart disease and stroke
• Functional impairment
• Cognitive impairment due to Alzheimer’s or other dementia
  Behavioral health diagnoses
• Frequent changes of residence for community-based individuals

​​Without effective care coordination and supportive care, risks for the CHSGa population include: 

• Inconsistent utilization of primary care
• Avoidable hospital admissions with length of stay or discharge complications
• Hospital re-admissions
• Repeat Emergency Department (ED) encounters
• Repeat 911 calls or 911 non-transport calls
• Potentially avoidable nursing facility placement
• Adverse drug events due to non-compliance and/or polypharmacy
• Unmanaged behavioral health conditions that impact physical health and social risks

The CHSGa network is patient-driven and data-supported, characterized by:

• Alertness for changes in condition and gaps in care, allowing for rapid response, better outcomes and effective use of resources
• Patient and family caregiver engagement in care planning and ongoing care delivery
• Patient navigation that promotes clinical integration and patient ease of the complexities before and during care transitions
• Health services provided by associates who live in the communities where they work, across the state
• Use of technology to advance optimal clinical care and patient experience
• Partnerships and collaboration within our own system and in the communities served
• Formal processes for concurrent review of care with participating organizations (including physicians, hospital and home health staffs) to ensure that parties communicate for preventive care, problem identification and taking action for efficient use of healthcare resources
• Addressing social drivers that contribute to poor health outcomes and the need for increasingly higher levels of care​​