Cercanos Care Is the Clinical Layer That Makes Value-Based Care Work

Cercanos Care is a medical group that manages cardiometabolic and behavioral health conditions exclusively in value-based care (VBC), working alongside the community physicians its patients already see. Its team of providers and health coaches in nutrition, behavioral health, community activation, and medication adherence operates across multiple states and patients with a variety of conditions.

The bulk of healthcare spending in the U.S. is driven by chronic conditions, with treatments largely based on the traditional fee-for-service model.

That's why value-based care and risk arrangements, with payments tied to actual health outcomes, are spreading across provider groups. Many providers are quick to agree to this model, only to realize they're not able to deliver on it. Getting patients with complex cardiometabolic and behavioral issues to target goals requires a longitudinal health record, clinical hours, a multidisciplinary team, and monitoring between visits. Most practices simply don't have the staff or infrastructure to take that on.

Traditional care management vendors promise to close that gap. Working from outside of the practice, with no ability to actually practice medicine, has obvious limitations however, leaving the provider group with the risk.

Care Management Plus: A Medical Group as the Clinical Layer

Cercanos takes a different approach to supporting providers in VBC arrangements. As a medical group with its own clinicians, Cercanos co-manages the provider's most complex cardiometabolic and behavioral patients as an extension of the practice. This clinical capacity helps providers reach quality and cost targets that would be difficult to achieve with brief office visits.

Cercanos clinicians write clinical notes, escalate on shared protocols, and adjust medications to support these patients. A consistent care manager stays in touch with each patient, establishing the person-to-person relationship that's critical for behavior changes that improve outcomes.

Demonstrating a health outcome requires knowing what happened to the patient everywhere else. Metriport assembles that picture from a range of sources so Cercanos can measure progress, close care gaps, and respond to events as they happen.

• A full history at enrollment. Enrolling a patient triggers a query to the national and state networks, and Metriport returns diagnoses, medications, prior encounters, and recent acute events before the care manager's first contact.
• The measures that matter. Metriport pulls the underlying values from a range of sources to provide relevant metrics including blood pressure, LDL-C, A1C, and weight, along with the PHQ-9 and GAD-7 scores that behavioral health is graded on.
• Gap closure and clinical notes. Metriport delivers dated lab results, medications, and diagnoses from across the network, so Cercanos clinicians can see which tests and screenings are overdue and document a note the community physician can rely on.
• Acute event tracking. Metriport's ADT feeds surface ED visits and other care transitions in real time, so Cercanos can intervene during the critical post-admission window.
• Escalation on protocol. Those same feeds flag care transitions and trigger the escalation paths Cercanos and the provider agreed to in advance.

These are critical resources for Cercanos, and the founders' experience steered them away from trying to develop them in-house.

Every Step Starts With the Record

Co-management runs as a repeating loop, and Metriport data enters at each turn. The provider refers a patient, the patient enrolls, and Cercanos builds a comprehensive care plan from the history Metriport returns.

Between visits the care team monitors and coaches on the areas where patients most often fall through the cracks: nutrition, medication adherence, polypharmacy, mental health, and social needs.

An ADT alert interrupts that cadence, and the team reaches out to the patient, escalating accordingly. Cercanos then sends a structured care update back to the practice for clinical review. In addition, the two teams review clinical outcomes, progress to goals, and joint priorities in a monthly meeting.

A History the Care Team Can Trust

Validating conditions against the record instead of reconstructing them from memory is especially helpful for patients with years of medication changes. The care manager's familiarity with the patient's language also helps when reviewing records, in ways an app with a translation feature would likely miss.

Reciprocity Versus Retrieval

Convenient record retrieval is helpful, but bi-directional sharing is essential for co-management. After Cercanos clinicians document a patient encounter, that data flows back to the network, keeping the community physician up to speed and both teams working from the same chart.

Patients who may have spent years with brief exams and inconsistent care are now managed continuously, by a team fully aware of their history and condition.

From Enrollment to Treatment in a Day

Before Metriport, the first step after enrolling a patient was sending record requests and calling offices and hospitals, often to receive incomplete records. Comprehensive treatment couldn't begin until the patient history was assembled, so every day spent chasing records was a day the patient went largely unmanaged.

Metriport removed that step. The query goes out at enrollment and the history comes back before the first contact, so the care manager opens each case aware of the patient's diagnoses, medications, and recent acute events. Patients move from enrollment to active treatment in one day instead of 14, and the constraint shifts from collecting information to engaging the patient.

Moving the Hardest Numbers

A1C and blood pressure are the measures cardiometabolic programs are graded on, and they're notoriously hard to improve. Moving them takes more than a prescription. It often means changing behaviors that have been ingrained for a lifetime.

Cercanos gets patients there. Its focus on relationship-building and informed care brings A1C into a healthy range for 75% of patients and controls blood pressure for 85%.

Utilization moves with the clinical picture: Cercanos achieves 48% fewer emergency department visits and 60% fewer hospitalizations, the two categories where avoidable cost concentrates and where a missed acute event turns into a readmission.

Satisfaction runs high on both sides of the co-management relationship, with a 98.5 NPS among patients and 100 among physicians. This perfect score reflects the provider's trust that Cercanos will help patients while keeping them engaged with the community practice.

Ready for Day One

The CMS ACCESS Model, launched in July 2026, ties payment directly to results. More than 150 organizations were accepted into the first cohort, including Cercanos, which participates in the eCKM, CKM, and behavioral health tracks.

Cercanos began enrolling patients on day one. Many others did not. Organizations that intended to go live in July found they underestimated the operational and technical requirements involved in coordinating care, collecting data, and reporting to CMS. With Metriport's support, Cercanos had its connections, data flows, and submission process in place ahead of time.

Whether value-based care scales depends on whether smaller practices can get the same data large health systems already have. These systems find it easier to obtain records and coordinate care because they control their network, but the majority of clinicians need access to records across institutions and systems. That access runs through health information exchanges, and few practices have the staff to build those connections internally.