Serves individuals (age 18+) who have Medicaid and meet the criteria for Health Home services. Will assist, support and monitor with the client all major systems. Designed to promote the indivduals optimal health, reduce unnecessary emergency room visits and inpatient stays while enhancing the efficacy of all systems with whom the individual is engaged. This will include but not be limited to; living arrangement, physical and behavioral health, economics, entitlements, vocational training and social, family, self-care and legal issues.