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The model uses a nurse-led, team-based approach that involves multiple professions working together to provide care for high-need, high-cost patients. Clinics use 4 simultaneous bundles of care that include evidence-based treatment guidelines, transitional care coordination activities, patient activation strategies, and behavioral health integration. Engaged patients indicate very high levels of satisfaction with care and improved physical and mental health outcomes resulting in significant cost savings for the health system. Finally, IPC

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