LT is known to many in St. Peter’s Health Partners (SPHP) in the Capital Region and the community at large. For years, LT went to the emergency room for his dialysis as opposed to receiving it in the proper setting of a hemodialysis (HD) center and he had become the most expensive patient in the SPHP system. Many of the SPHP team members have helped in caring for LT over the years. LT needed someone to sit with him during his HD sessions in the ED, to help ensure his visit was without incident because he occasionally exhibited disruptive and aggressive behaviors. During one of these visits, he was referred to the Health Home. They identified his anxiety as a root cause of his disruptive and aggressive interactions. Over the course of the following months, his Health Home Care Manager built trust with LT and convened team meetings with all of LT’s care team. They met several times to work together to create a plan that ultimately worked on directly addressing the Dialysis Center’s issues and LT’s issues. With the help of his Care Manager, LT started at the Center on July 1, 2018 and is still receiving dialysis at the Center. Since then, LT has only been to the ED once and hospitalized once. LT continues to have support from his Care Team coordinated by his Health Home Care Manager. LT’s Nephrologist states that he is in much better health now with consistent HD treatment. He is also better able to manage his behaviors. Not only has this transition benefited LT’s overall health, it has also dramatically reduced the cost of his care: In 2017, his total cost of care was $332,880.16 (137 ED visits and 3 inpatient visits) for the full year. In the 3rd Quarter of 2018, post intervention by the Health Home Care manager, his total cost of care was $5,431.