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People with multiple health and social needs are high consumers of health care services, and thus drivers of high health care costs. The elevated cost of care in this population offers a tremendous opportunity to understand the individuals and their priorities and needs, and to craft a service delivery plan that meets their needs more effectively at a significantly lower cost.

This IHI white paper outlines methods and opportunities to better coordinate care for people with multiple health and social needs, and reviews ways that organizations have allocated resources to better meet the range of needs in this population. There is special emphasis on the experience of care coordination with populations of people experiencing homelessness.

The framework relies on a methodical approach to delivering coordination services, not just health interventions, to improve health outcomes while ensuring efficient access to the health care system and other needed supports. The role of strong partnerships between health care and community organizations is highlighted and innovative test ideas are included.