Maximize the utility of Nextgen, Azara and other reporting systems to identify gaps in care for chronic disease management and preventative care, to proactively manage patients through centralized outreach or on-site huddle reports. Design and implement strategies to outreach to patients, who are high utilizers of the health care systems, to reduce ER visits and hospital admissions and engage them in regular consistent team-based primary care medical home (PCMH) visits.