Evaluation of Intensive Management Patient Aligned Care Team

Inclusion Criteria:

* Patient receives care from one of 14 primary care providers (MDs, NPs) who have at least three half-days of clinic per week
* Total VA healthcare costs in the top 5% for VA Palo Alto facility during the 9-month eligibility phase (10/1/11-6/30/12) AND/OR
* Risk for one-year hospitalization in November 2012 in the top 5% (using the VA's Care Assessment Need risk-prediction algorithm)

Exclusion Criteria:

* Enrollment in VA's mental health intensive case management program, home-based primary care, or palliative care programs
* Recipient of inpatient care for over half of the 9-month eligibility phase (10/1/11-6/30/12).
* Total VA healthcare costs in the lowest cost decile in the 9-month eligibility phase (10/1/11-6/30/12)
* Risk for one-year hospitalization in November 2012 in the lowest risk quartile (using the VA's Care Assessment Need risk-prediction algorithm).