Abstract
First we present a case vignette. Mollie is a 50-year-old woman with chronic, disabling back and knee pain, who has struggled with depression and alcohol misuse, is the primary caregiver for her ailing mother and a newcomer to the community. As a primary care patient at Dartmouth Health Connect, whose mission is "bringing humanity back to health care," Mollie receives exemplary person-centered care from her physician, health coach and behavioral health specialist. Second, we summarize the care model design features that enable care for people with challenging health and social circumstances. The design features include: primary care capitation, interdisciplinary team care, daily huddles and bi-weekly work rounds, and systematic use of patient-reported information and guidance.