This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes two guests from the Mile High Health Alliance: Dede de Percin, Executive Director, and Vicente Cardona, Program Manager. Dede and Vicente highlight how the grant was used to support the “Orange Flag” Project—an initiative that uses historic, predictive, and real-time data to inform emergency department personnel of a patient’s high utilization of emergency services to aid in care coordination. They talk about approaching the issue from a grassroots and systems level, the importance of collaboration with other organizations, what data tells us about high utilizers of ERs, and how they are working with medical providers to initiate protocols to improve outcomes.