Reinventing Rural Health

Main Street Health partners with existing primary care providers in rural America to make the transition to value-based care.

We Work With All Types of Rural Providers
  • Small Independent Private Practices
  • Large Group Private Practices
  • Rural Health Clinics
  • Critical Access Hospitals
  • Community Health Centers
  • Health Systems

We Value Community

We understand the value of community and building trusted relationships, and that is why we are present in each community we serve. We do that by embedding a local Health Navigator in every practice and hiring local teams in every market we serve.

A Health Navigator is an extra set of hands to assist you with doing all the little things you need to do every day to deliver the best possible care to the patients in your practice.

Learn More about how a Health Navigator can help you!
Partnership Profiles

Meet Dr. Commie Hisey

Dr. Hisey is partnering with Main Street to deliver high quality care in Texas.

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Partnership Profiles

Meet Dr. James Batey

Dr. Batey explains how Main Street is improving his care team's productivity in Obion County, Tennessee.

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Partnership Profiles

Meet Dr. Jennie Eckstrom

Dr. Eckstrom is partnering with Main Street to provide new resources to her team and patients in Montana.

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Partnership Profiles

Meet Dr. Timothy Smith

Dr. Smith is partnering with Main Street to help his team prioritize their focus on patient treatment and care planning in Iowa.

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Partnership Profiles

Meet Amy Smith, PA-C

Amy is a physician assistant partnering with Main Street to ensure her patients receive the care they deserve in West Tennessee.

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Partnership Profiles

Meet Dr. Wess Blackwell

Dr. Blackwell is partnering with Main Street to prepare for the transition to value-based care in Fayette County, Texas.

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Partnership Model

Local Health Navigator
Clinical Assessments
Quality Measures
Community Resources Coordination
Patient Education
Transitions of Care
Care Coordination

Local Health Navigator

Our Health Navigators are local to your community!​ Our Health Navigators provide an ‘extra set of hands’ in the clinic to help patients navigate care and reduce burden on the clinic staff.

Clinical Assessments

Data-driven assessments are completed during routine visits to identify clinical needs and treatment pathways for prevalent rural conditions.

Quality Measures

Closed-loop workflows ensure providers and Health Navigators address open HEDIS / STARs quality gaps.

Community Resources Coordination

Navigators surface social determinants of health barriers (e.g., food, transportation, housing, financial assistance) through patient check-in visits and connect patients with local and federal resources to close gaps.

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Patient Education

Health Navigators provide expertise and education on chronic conditions, medication adherence and understanding and maximizing their healthcare benefits including government-funded subsidies and cost-sharing for which they qualify (e.g., LIS).

Transitions of Care

Health Navigators review patient hospital admissions and discharges with clinic staff and conduct patient outreach to schedule timely follow-up care.

Care Coordination

Navigators work in clinics alongside staff to assist with care coordination, patient education, and value-based care activities.

Our Navigators are enabled by best-in-class technology.

Fragmented and complicated data systems make getting the right information at the right time difficult for providers and patients.

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Main Street maintains integrations across the healthcare ecosystem to digest and organize data.

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Main Street Technology

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Navigator Provider Partnership

Delivering you the insights you need to manage your patients’ health and conditions.

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High Risk Patient Engagement

Surface relevant clinical information at the point of care while real-time notifications prompt proactive outreach to patients to improve transitions of care and reduce readmissions.

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Closed Loop Workflows

Customized closed-loop workflows drive patient engagement, care coordination, and gap closure.

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Reporting

Daily, weekly, and monthly reports are provided to providers and practices to monitor trends and performance.

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