New approach aims to fix fragmented care for Society's most complex patients

This study is testing whether a new, proactive, and coordinated care model is better and more cost-effective than usual care for patients with multiple, complex health and social problems. It involves 200 patients across 20 primary care clinics who will receive a team-based approach, including a personal care plan and regular meetings with a doctor, nurse, and social worker. The main goal is to see if this integrated care improves patients' quality of life and experience while lowering overall healthcare costs.