The document discusses strategies for community-based chronic illness management to reduce costs and improve outcomes. It outlines several programs that have shown promise, including transitional care programs and house call programs. Transitional care programs of varying intensity use nurses and nurse practitioners to coach patients after hospital discharge. House call programs provide primary care to high-risk elderly patients in their homes through visits from physicians and nurse practitioners. Evaluation of these programs has found reduced utilization, lower costs, and improved outcomes and quality of life.