An innovative multi-disciplinary team that visits patients in their homes, discovering needs that would not have been identified through traditional health care strategies​.

Seeing and working with the patient holistically by understanding the patient's goals first, with recognition of the social determinants of health.​

A team that works with patients on their own goals, as well as their primary care provider, involving appropriate community support along the way.​

Finally, a team that offers culturally appropriate and sensitive healthcare practices.