JFK Medical Center’s Family Medicine Center, a Level III Patient-Centered Medical Home, will facilitate the continued development of this care model through four multidisciplinary teams comprised of physicians, nurse practitioners, nurses, medical assistants and support staff who will provide population management to high risk/vulnerable patients. Patients will be assigned to teams for coordination of care. The project will focus on the care of patients with diabetes, patients over age 75, patients with frequent inpatient or emergency room visits and depression. Based on previous success with Centering Pregnancy, an evidence-based model of group prenatal care, diabetes patients will receive medical care and education using the “centering” model. Using assessment tools such as interviews, Press Ganey surveys and a patient data registry, the project’s success will be measured based upon outcomes such as: a reduction in no-show rate for office visits; participation in diabetes “centering” groups and rates of emergency department utilization and hospitalization. The project aims to reduce costs while providing team-based, patient-centered care that will help to reduce morbidity and mortality and improve quality of life for high risk/vulnerable patients.