Delivered by trusted local partners, supported by
medical teams and AI-enabled tools
Our doctor-guided care navigators help patients and families stay strong, healthy, independent, and supported at home between primary care visits.
Trained Care Navigators deployed from pharmacies, senior services locations and mobile health vans provide health guidance for patients and families between clinic visits, with rehabilitation medical professionals providing oversight and additional support when needed.
Supports brain health across the full spectrum — from memory concerns and mood changes to dementia care. Care navigators help patients and caregivers monitor cognitive changes, support daily routines, coordinate dementia resources, and reinforce brain-healthy habits between doctor visits. They help track doctor-defined measures of cognitive functioning in between doctor visits.
Helps people stay steady, strong, and confident at home. Care navigators support fall prevention, physical activity, mobility routines, and early identification of changes that may affect safety and independence. They help track doctor-defined measures of relative fitness versus relative frailty in between doctor visits.
Supports daily management of conditions like high blood pressure, diabetes, and heart disease risk. Care navigators work to reduce social and other barriers that can get in the way of healthy lifestyle routines, medication adherence, and overall fitness. They reinforce and adjust care plans, monitor trends and help patients stay aligned with their fitness and lifestyle goals. Navigators help track our doctor-defined metabolic outcome targets in between doctor visits.
Supports emotional well-being, stress management, sleep, and daily coping. Care navigators help identify concerns early, encourage healthy social routines, and connect patients and families to appropriate behavioral health resources when needed. They help track our doctor-defined measurements of self-reported well-being in between doctor visits.
Supports daily management of musculoskeletal pain, arthritis, and mobility limitations. Care navigators help track pain patterns, functional ability, activity tolerance, and reinforce home exercise and safety routines, They help patients follow doctor-defined pain and mobility plans between visits.
As leaders in the delivery of enhanced aging support, we help patients keep score of their determinants for healthy aging and related functional abilities. To help motivate patients for taking good care of their health and function, we utilize a digital version of Harvard’s McCance Brain Care Score. This score makes it easy for us to help patients learn how best to target 12 major risk factors associated with conditions of the brain and body. These conditions include dementia, stroke, depression, other chronic conditions, frailty and post-hospital vulnerability.
The 5Ms of Age-Friendly Care helps care navigators focus on the things that matter
most for staying strong, healthy, confident and independent at home
Care navigation is not a single service — it’s an ongoing relationship. Patients and families are supported by trained Care Navigators who help translate medical guidance and prevention into everyday life. Rehabilitation medical teams provide oversight behind the scenes, reviewing information, guiding next steps, and ensuring that support is aligned with patient goals — without replacing primary care or specialty services. Our Care Navigators support the 5 KEY ingredients for aging well – brain health, mobility, cardiometabolic health, pain management and behavioral health.
Our care navigation programs are delivered through established community pharmacies and other partners — extending doctor-guided support into neighborhoods where people live.
Our care navigators use a secure digital platform and mobile app to help patients and families make sense of health information, follow through on care plans, and stay connected to their medical team. The technology supports everyday needs — tracking goals, organizing medications, noticing changes in health or function, and identifying when extra support may be helpful. Behind the scenes, doctors use the same platform to oversee care navigation, review updates, and step in when clinical input is needed.
Older adults with ongoing health concerns who want to stay independent, safe and active in daily life even as needs become more complex. We support everyday habits like physical activity, nutrition, medication routines, and goal setting to help manage blood pressure, cholesterol, energy and overall function.
Family members who want clear guidance, reassurance, and help coordinating next steps without having to figure everything out on their own.
Community-based staff including pharmacy teams, community health workers, mobile health units, and local organizations who want doctor-backed guidance, training, and infrastructure to participate in our CMS-aligned care navigation programs with sustainable reimbursement.
GamePlan Medical was founded by a rehabilitation physician focused on a simple but powerful question:
How do we help people live better — not just longer — as health and functional needs change?
Across proven rehabilitation models — including cardiac rehabilitation, pulmonary rehabilitation, and diabetes prevention program — the same pattern appears again and again: When people are supported in movement, thinking, daily habits, and sense of purpose, they maintain independence longer, improve cardiometabolic health, and experience a better quality of life. Care Navigators learn how to apply these same evidence-based rehabilitation principles to aging — including brain health — extending functional health support beyond the clinic and into everyday life.
We focus on the capabilities that matter most as people age — not just diagnoses or isolated conditions. That means improving fitness and metabolic health while preventing frailty. Supporting thinking and memory while reducing the risk of cognitive decline. Strengthening emotional well-being and life activities while reducing depression and social isolation. These goals are deeply connected. When people are supported across movement, thinking, daily habits, and purpose, they function better — and live better — at every stage of aging.
Most health outcomes are shaped outside of medical offices — where people live, move, eat, connect, pray, and participate in daily life. That’s why GamePlan Medical partners with community-based teams, including pharmacies and other local organizations, to deliver structured, doctor-guided support between clinical visits. Care navigators provide continuity, follow-through, and practical guidance. Doctors oversee care, review updates, and step in when clinical input is needed — without pulling people back into unnecessary appointments.
GamePlan Medical combines physician oversight, trained non-clinical care navigators, and simple, secure technology to extend medical guidance safely and at scale. This model allows community-based teams to participate in CMS-aligned programs — creating sustainable reimbursement for care navigation services that were previously unsupported. The result is a system that works for patients, families, clinicians, and community partners — without overwhelming any one group.
As healthcare continues to move upstream and into the community, GamePlan Medical exists to help people stay strong, supported, and engaged — long before crises occur. Through quality improvement collaborations that include the Global Brain Care Coalition, the Davos Alzheimer’s Collaborative and CPESN USA, we’re able to translate the latest brain health and aging science into practical, everyday guidance to build health and functional capacity within populations that include those living in rural and underserved locations. Community-based care navigation isn’t about doing more medicine. It’s about helping people live well, every day.
GamePlan Medical’s community-based care navigation model is built to align with CMS’s next generation bundled payment initiatives—supporting whole-person health, functional outcomes, and community-based delivery. Our care navigation teams are active today and designed to scale upstream.
• Guidance and care planning for daily function and routines, fall prevention, safety, medication and caregiver support
• Designed to compliment primary care—not replace
• Focuses on whole–person health and quality of life, making life easier and preventing crises
• Emphasis on improved blood pressure, cholesterol, and other metabolic outcomes through tech-supported coaching. Addresses barriers that can get in the way of outcomes
• Designed to complement—not replace primary care management by focusing on the upstream determinants of whole-person function
• Emphasis on daily function, frailty prevention, safety, and caregiver well-being.
• Designed to complement—not replace primary care management by focusing on the upstream determinants of whole–person function.
• Emphasis on coaching the underlying determinants for physical, cognitive and emotional function. Addresses barriers that can get in the way of outcomes
• Designed to complement—not replace
primary care management by focusing on the upstream determinants of whole–person function
We empower community organizations to participate in our CMS-aligned care navigation programs with sustainable reimbursement. Contact us to learn more.
