The Curators of the University of Missouri are receiving an award to provide enhanced primary care to Medicare and Medicaid beneficiaries receiving primary care within the University of Missouri Health System, many of them chronically ill. The program will use advanced health information technology, evidence-based treatment planning, and a specialized workforce to coordinate care for both patients and the existing health care team. Through support for disease self-management, improved delivery system design, focus on preventive care, and better decision-making tools, the intervention will strengthen primary care, reduce specialist referrals and the need for acute care, and improve patients' health.