1. It is possible to identify patients at high risk of having a hospital admission in the next 12 months. Most of these patients have one or more chronic diseases, as well as having behavioral health problems (substance abuse or mental illness). Many are not receiving timely and effective care outside the hospital and rely heavily on emergency rooms for much of their care, and many are socially isolated and/or have housing problems. What would an intervention look like for these patients, and what are the barriers to implementing it effectively?
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