To improve health, welfare and efficiency of care provided to North Alabama Eligible Medicaid Residents through compassion, innovation, coordination, and partnership collaboration. To develop and implement patient centered care plans and improve quality of care and quality of life. To improve health literacy, health outcomes and self management and the utilization of Information Technology resources. To promote effective use of the healthcare system and community resources and identify at high risk patients for care management. To prevent disease exacerbations and complications, and integrate evidence-based clinical practice guidelines, and to reduce inappropriate utilization and costs associated with Emergency Department and readmissions.