[1] Univ Penn Hlth Syst, Philadelphia, PA 19104 USA
[2] Penn Med, Ctr Hlth Equ Advancement, Philadelphia, PA USA
[3] Univ Penn Hlth Syst, Case Management & Social Work, Philadelphia, PA USA
[4] Univ Penn, Case Management & Software Informat, Perelman Sch Med, Philadelphia, PA USA
[5] Univ Penn, Perelman Sch Med, Ctr Community & Populat Hlth, Dept Family Med & Community Hlth, Philadelphia, PA USA
[6] Stanford Hlth Care, Stanford, CA USA
[7] Emory Univ, Sch Med, Atlanta, GA USA
[8] Univ Penn, Perelman Sch Med, Philadelphia, PA USA
[9] Univ Penn, Sch Nursing, Philadelphia, PA USA
[10] Penn Med, Penn Med Ctr Hlth Equ Advancement, Philadelphia, PA USA
[11] Univ Penn, Med & Pediat, Perelman Sch Med, Philadelphia, PA USA
[12] Univ Penn, Penn Med Ctr Hlth Equ Advancement, Perelman Sch Med, Philadelphia, PA USA