Consumers in community health face multiple burdens of economic fear, complex chronic conditions, highly variable incomes, and social determinants that create adverse outcomes. The organizations have to overcome challenges of language barriers, lack of trust in the system, cognitive disabilities to outreach to their communities and provide care. Harmony Health’s Hyper-Personalized Care Maps, collaborative care check-in’s, motivators for engagement, and incentives are designed to help organizations improve their quality outreach, health metrics, and increase reimbursement in capitated funding environments.