Patients with complex physical, behavioral, and social needs present unique challenges to the health care system, including disproportionately high costs. These patients are often sick, immobile, and alone. Their experiences in the health care system are fragmented and inadequate, and traditional clinic-based primary care pathways, with care being delivered in 15-minute increments or shorter, do not represent an effective way to contend with the significant medical, behavioral health, and social complexities that these individuals face. Mistrust pervades, and engagement is limited. Although new paradigms such as the patient-centered medical home have encouraged the integration of services, they have overlooked a crucial fact: namely, that we remain focused on where clinicians conduct their business rather than on where our patients live. In so doing, we have perpetuated systems of care that overly burden patients, unnecessarily exposing them to the risk of nosocomial infections, devaluing their time, and creating barriers to full access for those in the greatest need of dedicated and timely attention. …more