The OAH program combines Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, comprised of the Optum at Home team of clinicians as well as community-based health care professionals (e.g., PCP, specialists, behavioral health, pharmacy, and other providers). Optum providers serve people in their own homes through annual evaluations, longitudinal visits for higher risk beneficiaries, and care coordination during transitions from the hospital or nursing home and ongoing care management.