Provides care management to individuals with a serious mental illness, HIV/AIDS, or two or more chronic health conditions and significant behavioral, medical, and/or social risk factors, and who are in need of assistance linking to services to stabilize and improve their overall health functioning. Program services include outreach and engagement, comprehensive care management with assessment and care planning, care coordination and health promotion, comprehensive transitional care, client and family support, referral to community and social support services, and use of health information technology to link to services.