What follows is a patient story that illustrates how our typical interaction with a patient, social service agencies, and the community, as a whole, yields obvious value for the patient and for our health care system. Just like this case, we are able to decrease human suffering, expensive hospitalization, and the use of emergency services. In 2008, a local community agency called our team about a new client. The person, Sonia, was an 89-year-old retired secretary with no family. A retiree of modest means, she had stopped her weekly visits to her bank. Worried bank representatives found that she had fallen and was not feeling well. ...