Primary care settings play a critical role in providing care for people with complex health and social needs. Primary care practices, however, often lack the necessary resources to comprehensively address patient behavioral health and social needs, which are important drivers of poor health outcomes.

This Better Care Playbook In the Field profile describes how provider organizations in Rhode Island employ multidisciplinary teams, including community health workers and behavioral health clinicians, to collaborate with primary care practices in providing whole-person care. Evaluations of the Rhode Island-based program point to positive impacts, including reduced health care costs and improved health outcomes.