Effectively uses the following tools/strategies that include, but are not limited to: health risk assessments, predictive models (algorithm-driven models that use multiple inputs to predict high-risk opportunities for case management), surveys (e.g., PHQ-9, Short Form 12), case findings (e.g., chart reviews, surveys), referrals (from patients, providers, community). Improves overall patient care metrics as set by evidence practice medicine and recommended guidelines that are widely set for disease state/conditions that result in most health care expenditures as revealed in CMS chronic conditions literature and/or NGPG/NGHS cost data (i.e., heart failure, diabetes, hypertension, COPD/Asthma, pneumonia, depression and stroke).