The Inova Cares for Community Bridging (ICCB) clinics bridge gaps in care that patients experience as they transfer across care delivery settings between illness and recovery. The service focuses on transitional medical care and community collaboration to improve health outcomes of patients at the highest risk who lack access to needed resources. ICCB serves adult patients and accepts insurance from all payers and uninsured patients. Patients must have discharged from Inova Hospital or ED in the last 30 days and have an internal medicine diagnosis(es) needing post-hospitalization follow-up. ICCB has a primary focus on caring for high-risk patients without established PCP or who lack prompt access to one. ICCB is equipped to manage needs within the