University Hospitals (UH) Rainbow Babies and Children’s Hospital at UH Case Medical Center is receiving an award to improve care for approximately 65,000 children with Medicaid with high rates of emergency room (ER) visits, complex chronic conditions, and significant behavioral health problems in several counties across northeastern Ohio. The intervention will offer health care advice, referrals, and care coordination services through telehealth and home nurse hotlines; provide practice-tailored facilitation for primary care providers; and provide financial incentives to primary care physicians who reach quality performance targets, agree to offer extended hours, and make themselves available to treat these vulnerable children. Over 50 nurses, care coordinators and other health professionals will be hired and/or retrained to implement the model. The result should be better health care, with fewer avoidable ER visits, hospitalizations and lower cost— with an expected savings of over $13 million over three years.