Maria: From Crisis-Driven Care to Stability

Connecting members to the care and support they need, wherever they are.

María, a 58-year-old Medi-Cal member living with diabetes and asthma, had become reliant on the emergency room for care. Without a consistent primary care relationship and facing transportation and financial barriers, she lacked the structure needed to manage her conditions effectively. Her care was reactive, fragmented, and unsustainable.

01. Challanges

María’s challenges extended beyond her diagnoses—system fragmentation, limited access, and low engagement created compounding barriers to effective care. Without clear guidance or support, she struggled to follow care plans, leading to worsening health and repeated acute episodes.

  • Key Drivers

    • Medication confusion and inconsistent adherence
    • Missed appointments due to transportation barriers
    • No consistent primary care relationship
    • Limited understanding of care plans and next steps
    • Lack of coordination between providers

02. Approach

Through Enhanced Care Management, María was connected to a dedicated care team that provided consistent, relationship-driven support. The focus was on building trust, simplifying her care experience, and proactively addressing both clinical and social drivers of health.

  • Interventions

    • Weekly check-ins to maintain engagement and accountability
    • Centralized coordination across primary care and specialists
    • Simplified care plan with clear, actionable guidance
    • Appointment scheduling and transportation support
    • Connection to community resources addressing financial barriers

03. Outcome

With structured, ongoing support, María transitioned from reactive, crisis-driven utilization to consistent, proactive care engagement. Her health stabilized as she became more confident managing her conditions and navigating the system.

  • Outcomes

    • Reduced reliance on emergency room services
    • Improved medication adherence and consistency
    • Increased attendance at primary care visits
    • Better management of diabetes and asthma symptoms
    • Greater confidence navigating the healthcare system

Key shift: María moved from being overwhelmed by the system to being supported within it.

~70%+

Enhanced Care Management (ECM) – Care Coordination Impact

of DHCS quality measures tied to care coordination (MCAS) show improvement in access, timeliness, and continuity of care

Signal: ECM-driven coordination is directly improving member engagement and reducing fragmentation.

52%

Community Supports (CS) – Preventive & Whole-Person Care

of plans improved preventive care engagement (e.g., well-care visits) tied to upstream interventions and social supports

Signal: CS services (housing, nutrition, transitions) are contributing to better preventive care uptake and long-term outcomes.

90%

Behavioral Health (BH) – Follow-Up & Engagement

of plans meet benchmarks for follow-up after emergency department visits for substance use disorders (FUA/FUM measures)

Signal: Strong follow-up rates are improving stabilization and reducing repeat crisis utilization.

About Atlas Healthcare Alliance

Integrated Care Solutions

We deliver comprehensive, tech-enabled healthcare services designed to meet patients wherever they are. Through Emmebr Care, our model combines clinical expertise, care coordination, and digital infrastructure to streamline treatment pathways, improve outcomes, and reduce system friction for both patients and providers.

Patient-First Care Experience

Our approach is built around the individual. Emmebr Care prioritizes accessibility, continuity, and personalization—ensuring every patient receives timely, high-quality support across their care journey. From initial engagement to ongoing management, we focus on delivering a seamless, human-centered experience that drives better health outcomes.

Strategic Healthcare Partnerships

We collaborate with providers, payors, and healthcare organizations to expand access and optimize care delivery. Through Emmebr Care, our partnerships are designed to align incentives, enhance operational efficiency, and unlock scalable solutions that benefit both patients and the broader healthcare ecosystem.

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Coordinated care improving community health and wellbeing

Advancing Healthier Communities

Our mission is to advance healthier communities by delivering coordinated care management, behavioral health services, and community-driven support systems that address the full spectrum of medical, behavioral, and social needs. Through collaboration with healthcare providers, community organizations, and trusted community health workers, we connect individuals to the resources, services, and support necessary to improve health outcomes, promote stability, and empower members to live healthier, more independent lives.

Aligning healthcare, services, and community partners together.

Removing Barriers to Care

Our purpose is to remove barriers to care by aligning healthcare providers, social service organizations, and trusted community partners to deliver coordinated, person-centered support. By integrating medical care, behavioral health services, and community-based resources, we address the social and environmental factors that influence health and well-being. Through collaboration, culturally responsive engagement, and community health worker outreach, we ensure individuals can access the services, guidance, and support they need to navigate complex systems, stabilize their lives, and achieve improved health outcomes.

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