Boston Medical Center Health System (BMCHS), a leading safety net organization, delivers high quality care to Medicaid and underserved populations through an innovative and multidisciplinary Population Health team. To strengthen outcomes for affiliated accountable care organizations, the team launched a centralized outreach program designed to close persistent gaps in behavioral health, perinatal care, and chronic disease management. This model replaces fragmented, clinic-based workflows with timely, clinician supported outreach that meets patients where they are, reduces barriers to care, and improves performance on key MassHealth quality measures. Through initiatives such as the Follow-Up After Hospitalization for Mental Illness (FUH) program, trained behavioral health clinicians connect with patients immediately after discharge, providing real time support, care coordination, and clinical assessment to enhance continuity and safety. Similarly, our postpartum outreach program offers flexible telemedicine visits that help new parents overcome challenges while ensuring timely, comprehensive postpartum care. Complementing these efforts, COACH-BP is a hypertension telephonic follow-up program that helps empower patients with education, home monitoring support, and rapid connection to care teams. Collectively, these centralized clinical outreach strategies elevate patient experience, improve health outcomes, and reinforce our ability to achieve strong ACO quality performance that sustains BMCHS’s critical safety net mission.