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other changes in health or functional status arise. Care coordination for complex patients starts with a comprehensive assessment of each individual’s need for health and social supports. Patient-centered: The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person.

 

We first discuss the importance and potential benefits of transforming current PCPs to serve these complex-needs population groups (Chapter 2). We then turn to the current challenges that prevent many primary care clinicians from doing so (Chapter 3) and

 

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