Abstract: A system (200) and method (500) is provided for a coordinated health care service delivery program. The method can include providing services to clients at high risk for chronic disease including co-morbidities and consequent disabilities associated with the chronic disease, linking community and vocational services (130) for facilitating community inclusion to supplement fundamental clinical and economic goals, creating a comprehensive and dynamic individual development plan (222) to involve the client and family members as active program team members for stressing client-centric collaborative goal setting, and applying action learning (226) to promote behavior modification and lifestyle change.