Four Pillars Driving Impact
Team-Based Care
Data Empowerment
Patient Engagement & Education
Standardized, Flexible Playbooks
1. Team-Based Care
At the heart of Accompany Health's success is a tightly coordinated care team that extends far beyond what most primary care practices can offer. Physicians and Advanced Practice Clinicians (APCs) lead with medical expertise, while nurses and pharmacists provide a second layer of vigilance, helping adjust medications, catch complications early, and ensure chronic conditions are tightly managed. All members of the care team are Accompany Health employees, enabling tight coordination and rapid action to close care gaps effectively.
Having the team approach and making sure people understand why these things are important, and how each member of the team can support, has been super impactful.
— Alicia Schumacher, CHW and Market Operations
Community Health Workers (CHWs) are the vital bridge between clinic and home. In Detroit, CHWs regularly accompanied patients to specialist appointments—helping them navigate diagnoses, understand next steps, and follow through.
Visit accompaniment is a simple but powerful way we ensure patients get the care they need. This support builds confidence, prevents cancellations, and ensures vital information flows back to the care team—making care more accessible, understandable, and actionable.
I've had a CHW go to three different colonoscopy appointments too, just because the patient didn't have someone to go with.
— Jennifer Legge, NP, Advanced Practice Clinician
They also helped patients over the "last mile" of preventive care, delivering FIT kits, explaining how to complete them step-by-step, and checking in to ensure completion.
If the answer is no, let's walk through why. Maybe they just forget. Maybe they need a video. I can send them that. And I'm willing to answer questions
— Alicia Schumacher, CHW Operations
2. Data Empowerment
Accompany Health's tech platform equipped care teams with real-time insights, supporting everything from performance tracking to patient-specific interventions. Its population health intelligence engine provided risk stratification, segmentation, and analytics that enabled precision targeting and timely responses.
Actionable data allowed teams to take a "use every opportunity" strategy, where every patient touchpoint was an opportunity to close quality gaps. This all-hands-on-deck approach directed frontline team bandwidth to highest impact actions and create a patient-centered care plan.
Just being able to look at [gaps] from a finer microscope and say, 'This is the gap, this is where we're at, and this is how each person can support,' has been huge.
— Alicia Schumacher, CHW and Market Operations
Pharmacists used data visibility to preemptively reach out to patients struggling with medication adherence and streamline formulary navigation. Nurses reviewed hospital admissions data to provide real-time outreach to patients, often preventing readmissions by connecting them to outpatient services.
The team flagged crucial medications that were missing and noticed signs that would indubitably lead to an ED visit. We got the correct medications delivered that day, and coordinated with the PCP to update future adherence packaging.
— Lauren Taylor, RN, Nurse
3. Patient Engagement & Education
Patients were engaged through omnichannel outreach and supported with hands-on coaching. From CHWs explaining red zone symptoms in CHF to nurses helping patients organize pills and appointments, education was personalized and practical.
Patient had concern for a small seizure, nosebleed – we immediately called to check in. The patient had already gone to Urgent Care but was overwhelmed with gratitude. 'I can't believe you actually called me... I've never had a company care like this.'
— Keirstin Diller, Patient Support Representative
Teams were trained in motivational interviewing and framed care plans around what matters to each patient. When one patient refused insulin due to fear, a nurse and CHW coached her through the first injection.
The last mile runs through everything we do—because delivering quality means more than designing great care; it means making sure it actually works for the patient in real life.
Just making sure people have a cuff, scale, or pill box, and even programming reminders into their phones, makes a big difference.
— Alicia Schumacher, CHW and Market Operations
She told the team she felt more confident... We also placed her continuous glucose monitor and got her app actually working.
— Casey Henritz, DO, Medical Director
4. Standardized, Flexible Playbooks
Measure-specific playbooks made quality workflows replicable, consistent, and scalable. These were embedded in team huddles and tracked in Accompany Health's task system, driven by a workflow engine that ensured follow-up, documentation, and accountability.
Patient Experience Navigators and Community Health Workers (CHWs) triaged insurance coverage and escalated access to payer benefits like home testing, transportation, and devices.
We collaborate closely with our payer partners to align on benefits, coordinate outreach, and share information in real time. Together we can reach members more effectively and ensure continuity of care.
Showing them their range, and explaining how it links to daily blood sugars, really excites patients to know where they stand.
— Jennifer Legge, NP, Advanced Practice Clinician
Having a team approach, making sure people understand why these things matter, was a game-changer.
— Alicia Schumacher, CHW and Market Operations
Colorectal Cancer Screening
Strategy
- Accompany Health integrates colorectal screening into routine patient touch points by embedding education and test distribution into existing care relationships.
- CHWs deliver FIT kits during home visits and pair them with consistent follow-up, transforming CRC screening from an abstract recommendation into a relationship-driven intervention.
- Visit accompaniment is a last mile intervention that is a simple but powerful way to ensure patients get the care they need.
The patient had a positive FIT test for in 2024 but had been declining a follow up colonoscopies screening. After discussing, she understood its importance and was so motivated she called the clinic while she was right in front of me to schedule it.
— Dominique Couture, NP, Advance Practice Clinicians
Lessons Learned
- Coordination across CHWs, PENs, and clinicians is key.
- Behavioral nudges (in-person delivery) outperform passive methods.
- Escalation works best when framed as support, not punishment.
Breast Cancer Screening
Strategy
- CHWs support appointment scheduling, transportation, and education, addressing the most common obstacles to follow-through.
- CHWs build trust through consistent, culturally sensitive interactions during home visits, reinforcing the importance of mammograms.
- Multi-source data to identify gaps and progress towards gaps to inform next best actions across the care team. Data are refreshed and directly accessible to teams and managers.
- Use of simple handouts and short videos to make care easy to understand and build trust with every patient.
Having results from their last mammogram in hand helps show it’s time to get back on track.
— Jennifer Legge, NP, Advanced Practice Clinician
Lessons Learned
- Direct scheduling and accompaniment to appointments boost follow-through.
- Trust-building is especially critical for mammogram uptake.
Statin Adherence
Strategy
- Pharmacy techs are embedded in care teams to coordinate refills, answer medication questions, and work alongside CHWs to identify and resolve barriers like side effects or insurance challenges.
- APCs initiate prescriptions during visits, while CHWs reinforce adherence through regular follow-ups.
- Multi-source pharmacy data aggregation, summarization, and tech enablement for pharmacy-led interventions.
After 3 months of follow-ups and support, my patient is off insulin and has an HbA1c of 8.2%, just by listening to his needs.
— Dominique Couture, NP, Advanced Practice Clinician
Lessons Learned
- Collaborative workflows between pharmacy techs and CHWs reduce barriers.
- Addressing formulary issues early prevents medication delays.
Diabetes Management (A1c, Kidney, Eye Exams
Strategy
- Home lab partners support A1c and kidney testing in patient homes, removing the need for travel to clinics or outpatient laboratories.
- CHWs provide personalized coaching and education, while pharmacy techs ensure medication refills are seamless, supporting holistic diabetes management.
- Patients are given practical adherence tools like pillboxes and adherence packaging.
- Reducing barriers to use of CGM through streamlined technology and white glove processes
A patient enrolled in our Diabetes Program started with an A1C of 13.2. After we explained how it connects to daily blood sugar, she began using her CGM consistently and brought it down to 7.9. Her first question on follow up was “How can I get it below 7?"
— Jennifer Ertelt, RN, Nurse
Lessons Learned
- Home labs reduce friction and boost screening rates.
- Bundled care with relationship-based approaches improves outcomes.
Post-ED Follow-Up
Strategy
- Care Team Managers (CTMs) coordinate discharge planning with APCs and CHWs, ensuring follow-up occurs within 48–72 hours.
- This integrated approach includes medical reviews and addressing social needs, often via in-home or virtual visits.
- Food, medication, and post-discharge care coordination needs are always reviewed at a baseline.
- Robust interoperability strategy to maximize coverage of data signals of all attributed patients for ED and hospital admissions (ADT) and curation and summarization of records.
Follow-up isn’t just one call, it’s CHWs, APCs, the entire team ensuring patients know what to do next.
— Jennifer Legge, NP, Advanced Practice Clinician
Lessons Learned
- Early outreach (48–72 hours) is most effective.
- Patients appreciate when follow-up includes non-medical needs.
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