This program provides targeted outreach to patients in high or rising prospective risk categories. Scoring is based on utilization, readmission risk, new diagnoses and/or significant medical spend within the last year. Community Healthcare Coaches contact patients, review medical information, conduct brief assessments with patients, and address any barriers to accessing healthcare services. Additionally, Community Healthcare Coaches discuss healthcare goals, management of chronic conditions and determine eligibility for appropriate disease management programs, educational services and community resources. Community Healthcare Coaches work with patients to determine next steps and the frequency of follow-up and notify primary care providers and/or specialists of outreach and interventions.