Beacon CareNation is a group of Nurses, Social Workers and Health Coaches who coordinate and manage patients' healthcare needs using a holistic approach. The goal of the Beacon CareNation team is achieve, for their patients, an optimal level of wellness while arranging for cost-effective, non-duplicative services, across the continuum of healthcare. Every effort is made to manage patients' health on an outpatient basis, avoiding unnecessary trips to the Emergency Department and hospital admissions. Beacon CareNation is part of a larger organization called Beacon Health Partners, a Long Island based Accountable Care Organization and Independent Practice Association, comprised of more than 1,100 physicians. Physicians in the Beacon network refer to Beacon CareNation if their patients: frequently interact with the healthcare system, are chronically ill, and/or are in need of additional assistance managing their condition(s). Beacon CareNation can assist with anything from helping a patient obtain transportation to doctor appointments to arranging homecare to attaining Durable Medical Equipment. The efforts of Beacon CareNation will ultimately result in a healthier population, decreased cost of healthcare and increased patient satisfaction