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Mount Auburn Cambridge Independent Practice Association has been awarded a Harvard Pilgrim Health Care Population Management grant to expand its integrated multidisciplinary team approach to managing patients with multiple chronic diseases. A Systematic Case Review (SCR) Team consisting of Care Navigators, Social Workers, a Pharmacist, an Endocrinologist, a Cardiologist and a Psychiatrist conduct reviews of patients who struggle with chronic disease management of diagnoses ranging from diabetes to chronic hypertension. The SCR Team communicates medical and pharmaceutical recommendations that incorporate behavioral and psychosocial care back to the primary care physicians. MACIPA’s care navigators, who have direct contact with patients, deliver and support the well-rounded plan to the patients, which helps to improve the clinical outcomes as well as the overall wellbeing of our patients. We continue to track relevant NCQA (National Committee for Quality Assurance) measurement outcomes to demonstrate this intervention effectiveness.