The aim of this study is to assess the effectiveness of Telephone-Linked Care for Complex
Patients (TLC-C) in the care of patients with complex health care needs. These are patients
frequently transitioning from inpatient to ambulatory care with multiple chronic diseases
that tend to lead to increased health-care utilization and other socio-economic
vulnerabilities. The objective is to reduce preventable hospital utilization, improve quality
of life, increase satisfaction with ambulatory care, improve disease-specific metrics, and
reduce net payer costs.