National health care reform has begun a dramatic shift towards highly coordinated, patient-centered care. The goal of this grant is help the Institute—one of the State's largest community health centers with 27 locations—to improve care and outcomes for high-need patients by training staff in shared care planning, coordinating care among patients' multiple providers, expanding the Institute's ability to track care through the electronic health record and outside data sources, and sharing best practices, lessons learned, and training materials with other providers.