Ranked as one of the top ranked New York hospital by U.S. News & World Report, NewYork-Presbyterian (NYP) has a long tradition of bringing hope, health and healing to our communities. NYP’s commitment to addressing the specific needs of its local communities shines brightly through the work of its Ambulatory Care Network (ACN) and Division of Community and Population Health (DCPH). The ACN and DCPH is comprised of 14 primary care sites, seven school-based health centers, 13 mental health school-based programs, and over 60 specialty practices. It also oversees over 20 community programs, including a NYS Health Home Program. The Comprehensive Health Program (CHP), the site of this position, is a center of excellence for HIV treatment and prevention as well as sexually transmitted infections and general infectious diseases. To address social determinants of health and mitigate risk for poor outcomes among vulnerable populations, CHP has embraced comprehensive care coordination strategies and practices multidisciplinary, team-based care including integrated behavioral health services, intense care coordination and primary care. Patients are cared for by a team of multidisciplinary providers (care coordinators, SW, RN and primary care provider) and are offered Health Home enrolment as part of this comprehensive care. NYS’ Health Home programs are designed to address complex and high-cost medical conditions and to address medical, behavioral and social needs comprehensively. Care teams work collaboratively to develop patient-centered care plans that empower patients to be an active participant in his/her health care.