and referral to food resources such as referral to the SNAP program, the WIC program, a food bank, case management assistance, employment or education support, intimate partner violence, and behavioral health support). (C) Home and community-based services that provide collaborative care to address mental and physical health comorbidities through health behavior services, nutrition support, medication management, transitional care, telehealth, mobile integrated health care, paramedic-based home visitation, or utilization of community health workers. (D) Hospital-based interventions (such as same day primary care services, skilled nursing interventions, substance use disorder and behavioral health treatment coordination of care, collaborative care models, discharge planning and medication reconciliation, long-term care management, and post-traumatic injury management). (5) Individual with mental and physical health comorbidities The term individual with mental and physical health comorbidities means an individual who is challenged by serious mental illness or serious emotional disturbance as well as 1 or more of the following conditions or characteristics: (A) Has or is at risk for one or more chronic conditions (as defined by the Secretary). (B) High-risk pregnancy. (C) History of high utilization of acute care services. (D) Frail elderly (defined by impairments in activities of daily living). (E) Disability, including traumatic brain injury. (F) Critical illness or injury requiring long-term recovery. (6) Vulnerable community The term vulnerable community means a geographic area served by an eligible hospital characterized by a population that has a statistically significant number of individuals with mental and physical health comorbidities, indicators of poor population health status, low-income status, or status as a USDA-recognized food desert. (g) Evaluation and report Not later than 1 year after the date of completion of the program under this section, the Secretary shall submit to Congress a report