Our team-based model of care focuses on the whole person

MHN's proven team-based model has always focused on whole person health by addressing medical, behavioral and social needs. We do not just provide care management, we link it to community-based primary care. At the heart of this model are care teams who are hired by the primary care practice from the communities they serve and provide culturally competent care. Our care teams work to meet patients where they are in order to build trusting relationships, which helps them become fully engaged in their care and results in better health outcomes.

MHN's model and approach empowers federally qualified health centers to transform care and build the right capabilities to be successful under value-based care. 

MHN model of care: key components

  • Delivery redesign: Enabling safety net providers to work together to provide better whole-person care across the health care continuum.
  • Practice innovation: Transforming the way care is managed at the practice level.
  • Patient engagement: Building relationships with patients and their care teams that go beyond the four walls of the practice.
  • Closing the disparity gap: Increasing access and quality of care for safety-net populations.
  • Building capabilities: Empowering FQHCs to be successful under value-based care.

Transitions of Care Nurses: Big Connectors for Vulnerable Patients

A vital member of the care team is the Transition of Care (TOC) nurse, whose responsibility is to transfer a patient’s care from one setting or level of care to another — but they do much more. Meet two of MHN's Transition of Care nurses who are making a big impact.

Read their stories