Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: - Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.- Including through the use of tools that facilitate electronic communication between settings;- Screen patients for health-harming legal needs;- Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or- Provide a guide to available community resources.