Consider adding another assumption or expanding the "Patient has access to patient portal and can use portal to review and update electronic information" to be that the patient has access to Wi-Fi and Internet and Wi-Fi/internet enabled device(s) such as a smart phone or tablet. These are not available to all. Devices and internet access comes with a cost to the patient. This further reduces their ability to locate and interact with available community services.

(Comment 223 - imported by: Robert Dieterle)