"[Doctors] can give you advice, like, 'Here's the kind of medicine you need.' But they don't really know how it works in the real world." Summed in just two sentences, a patient from the University of Pennsylvania Health System succinctly encapsulates the disconnect between health care professionals and at-risk patients who have difficulty effectively self-managing their conditions. For patients dealing with a range of non-clinical barriers to health—from unemployment to food deserts—clinical care isn't enough to improve long-term health outcomes and care utilization.