ConcertoHealth is a risk-bearing provider group that delivers high touch, individualized field-based care to persistently high cost and at-risk populations. ConcertoHealth multidisciplinary team members “meet patients where they are, and when they need us the most”, whether in their home or the hospital. ConcertoHealth continually analyzes patient data and monitors hospital admission and discharge feeds to determine the appropriate level of intervention for each patient. Rather than simply creating a care plan that encourages and refers patients to care, ConcertoHealth delivers care as a treating provider based on patient needs. These needs include addressing social determinants of health such as transportation and social isolation, cognitive impairment, behavioral health conditions, and palliative care.