This session will discuss the collaborative creation of a model of care to address members who are identified as high risk for hospitalization and/or ED utilization. The model of care incorporated the Arizona Complete Health’s Medicare Advantage plan’s data, engagement and retention teams, and core leadership, along with the Adobe Population Health, a population health organization’s proprietary risk stratification tool, case management team, and house calls program. The use of data analytics identifies the at-risk population which are then assessed using the population health company’s SDOH app MASLOW© to identify social risks. The in-home provider utilizes a hybrid model with an in-person medical assistant in the home while the provider conducts the telehealth visit. Together the health plan team, the population health team, and the in-home provider create a plan of care to address the issues that have led to high utilization of hospitalization and ED visits. The model addresses: • Member Engagement • SDOH risks • Increase in provider utilization • Reducing readmission rates • Decreasing ED visits Healthcare leaders, case managers, data and analytics teams and anyone who is interested in understanding and discussing a model to improve outcomes for a high-risk population is encouraged to attend.