The Community Team utilizes an integrated care model with a whole person approach designed to improve the care of a targeted group of members with complex needs and high costs of care, including individuals with both physical and behavioral health conditions. The team-based approach draws on the unique skills of nurses, social workers, certified peer specialists/ community health workers/health coaches, as well as pharmacist and medical director support to assist members with complex needs and high utilization of inpatient care. Contact is established face to face in the hospital followed by ongoing visits and support in the members' homes to create therapeutic bonds, help build members' knowledge and self-management skills, improve care coordination among their providers, and identify and help overcome medical and psychosocial barriers to care. The Community Team health coaches meet and engage members in the community, establishing rapport, assisting with transportation needs and often accompanying members to physician visits. They help to improve members' understanding of their current health conditions, conduct psychosocial assessments and use motivational interviewing to identify members' goals and pinpoint their readiness to change. By meeting with members on their terms in their homes and communities, the health coaches are better able to understand the factors that affect their motivation and leverage those factors to promote personal responsibility in members' everyday choices for positive health outcomes.