 - Has complex healthcare needs as defined by having two or more IOM Institute of Medicine priority conditions hypertension, coronary artery disease, congestive heart failure, stroke, asthma, diabetes OR one of the following: moderate to severe mental health diagnosis schizophrenic disorder, episodic mood disorder, delusional disorder, non-organic psychosis, anxiety, dissociative-somatoform disorder, personality disorder, end-stage renal disease, sickle cell disease 