Inclusion Criteria:  Hospitalization in prior 12-months Received post-acute care in prior 12-months (skilled nursing facility or skilled home health care) Two or more chronic conditions Two or more activity of daily living impairments or greater or equal to six Frailty Index score Less than or equal to 60 minutes of closest VA primary care site.  Exclusion Criteria:  Enrolled in Home Based Primary Care Using hospice Care Using palliative care In a foster home In a nursing home