Our hybrid care delivery system addresses the obstacles to high-quality care that aging, rural or complex patients and their doctors face. Especially individuals with chronic conditions and comorbidities that are unaddressed or undermanaged. We reconnect patients with primary care physicians. Our model involves a dedicated medical assistant physically present to help patients; an administrative staff to manage the logistics; and a team of specialists delivering expert medical care via telehealth. Integration is key to addressing the fragmented care and poor health outcomes that can result when benefits are not coordinated. In-person staff help patients get comfortable using the digital tools such as remote monitoring and access to medical records. The doctors are able to manage continuity of care and see patients sooner, leading to earlier diagnoses. We thus aim at resolving and preventing critical events, controlling chronic conditions, decreasing avoidable hospital admissions, ensuring safe care transitions and improving self-management skills.