Project Goal: Sustain and expand the ZSFG Social Medicine program by September 2020 via a) Securing $2M in financial support to grow team; b) Investing in staff engagement and professional development, and assessing measures of teamwork and engagement; c) Developing new internal and external cross-sector partners to expand service delivery – e.g., housing + substance use linkage; d) Scaling this team-based model of care to ZSFG inpatient and psychiatric units, and 1 outside hospital; e) Tracking # patients served, # admissions/readmissions averted, % reduction in return ED visits, % reduction in non-billable lower-level-of-care inpatient days; and f) Disseminating work via academic publication and other forums.