Our Population Health Management Capabilities – Southland Care Coordination Partners, Inc.

Capability	What SCCP Provides	Value to Partners
HEDIS & Quality Gap Closure	Member outreach, scheduling, documentation capture, clinical escalation, and measure-specific workows.	Improves quality performance, Star Ratings, value-based care outcomes, and payer/provider accountability.
Care Coordination	Ongoing member follow-up, appointment coordination, care transition support, and barrier resolution.	Reduces missed care, strengthens member adherence, and improves continuity across sellings.
Behavioral Health Follow-Up	Support for FUH, FUA, and FUM 7-day and 30 day follow-up engagement using trained behavioral heals clinicians.	Improves post-discharge engagement and supports high priority behavioral health quality measures.
Clinical Quality Support	Nurse practitioner, registered nurse, LSW, and LCPC suppart for salected quality assessments, chranic disease follow-up, triage, and member counseing.	Moves outreach beyond reminders into cinically meaningful interventions.
Preventive Care Navigation	Scheduling and follow up support for screenings, wellness visits, prenatal postpartum care, and preventive services.	Increases completed services and reduces avoidable quality gap
NEMT Logistics support	Transportation coordination and follow to help members access necessary medical appointments and services.	Reduces access barriers and improves service completion.
24-Hour Triage support	RN-supported triage call service using evidence based protocols for cient populations.	Supports timely guidance, reduces unnecessary utlliization, and extends care-learn capacity.
Member Engagement Campaigns	Structured call campaigns, cohort outreach, reminder workflows, escalation tracking, and reporting.	Creates scalable outreach infrastructure without requiring partners to expand internal staffing.

How SCCP Supports Better Outcomes

1. Identify the Population	2. Engage the Member	3. Resolve Barriers
We work from targeted member lists, quality gap fies, high-risk cohorts, or delegated populations.	Our outreach tears contact members using structured workflows designed to buik trust and improve completion rates.	We help address appointment access, transportation concerns. confusion about services, care avoidance, and documentation gaps.

4. Coordinate Services	5. Escalate Clinically	6. Report Results
We schedule appointments, support follow-up. confirm completion, and reconnect members to providers and health plan	When needed, NPs, RNs, LCSWs, LCPCs, and behavioral health clinicians provide appropriate support and follow-up.	Partners receive actionable reporting on outreach attempts, closures, pending gaps, refusals, barriers, and escalation outcomes.