This document discusses a program between Sutter Health's Alta Bates Summit Medical Center and local community health clinics to improve access to primary care for patients who frequently use emergency rooms. The program places registered nurses in three Oakland and Berkeley clinics to help establish a primary care physician and ensure follow-up care after ER visits or hospitalizations. An analysis found the program led to a 32% increase in follow-up primary care visits, 17% decrease in ER visits, and 17% decrease in hospital readmissions within 30 days. The program aims to provide more appropriate and convenient care to reduce costs while improving outcomes.