2.a.i: Create Integrated Delivery Systems that are focused on Evidence Based Medicine/Population Health Management
2.a.iii: Health Home At-Risk Intervention Program
2.b.iii: ED care triage for at-risk populations
2.b.iv: Care transitions intervention model to reduce 30 day readmissions for chronic health conditions
3.a.i: Integration of primary care and behavioral health services
3.b.i: Evidence based strategies for disease management – Cardiovascular Disease (CVD)
3.c.i: Evidence based strategies for disease management – Diabetes
3.d.ii: Expansion of asthma home-based self-management program
4.a.iii: Strengthen mental health & substance abuse infrastructure across systems
4.c.ii: Increase early access to, and retention in, HIV care