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 staff members from West Mountain Regional Health Alliance—Christina Gair, Executive Director, and Namrata Shrestha, Assistant Director. Grant funding went toward a care coordination effort to support individuals experiencing homelessness with coordination by hospitals, health and behavioral health providers, community organizations and government agencies. The discussion looks at the challenges of coordination across multiple organizations and different workflows, consideration of factors such as social needs (e.g., food, housing, transportation) and behavioral health, and the importance of creating a useful tool that helps “connect the dots” for care teams.