LifeWays Community Mental Health and the Center for Family Health, a Federally QualifiedHealth Center (FQHC) and other primary care providers, will partner to increase the life expectancy and improve the overall health of individuals living with multiple chronic physical and mental health conditions. This collaboration, known as the LifeWays Health integration Project, will effectively and efficiently integrate the health care of these individuals through the delivery of comprehensive care management, care coordination, health promotion, comprehensive transitional care from inpatient to other settings, individual and family support, and referral to community and social support services. This integrated approach will also include coordinated, accessible, and seamless access to primary care services within the behavioral health care setting and tailored to best suit the needs of the individual. The project will serve 100 individuals in Year One, 250 individuals in Year Two, 400 individuals in Year Three, and 500 individuals in Year Five. This project includes three goals: 1) improving the health of individuals with high co-morbidities and serious mental illness through the reduction of health risks including: blood pressure, body mass index, waist circumference, breath CO, and fasting plasma as outlined by the Million Hearts Initiative; 2) improving the wellness of individuals with high co-morbidities and high SMI through identification and reduction of risks associated with social determinants of health including: vaccines, cancer/preventive screenings, dental, optical, auditory and basic needs; and 3) easing coordination of care amongst partnering treatment teams through improved health information technology and information exchange.