The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,1 which totaled $402 billion in 2006. American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in America will soon become unsustainably expensive (Box 1).2 The answer may be Patient-Centered Coordinated Care (PtC3). PtC3 is an assessment-based interdisciplinary approach to integrating health care and social support services in which a patient’s individual needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored through a high touch approach.