… issues, a lack of understanding of discharge instructions, and unmet social needs such as food insecurity or lack of transportation. These are precisely the types of … Leveraging Team-Based Care Models: Within models like the Patient-Centered Medical Home (PCMH), family physicians lead collaborative care teams. Predictive … 2025 Apr 28 [cited 2025 May 1]; Available from: https://www.sciencedirect.com/science/article/pii/S0735675725003092 3. Kijpaisalratana N, El Ariss AB, Balk …