As a community, aligning efforts across a community to support the safety and well-being of vulnerable and under-served individuals is extraordinarily difficult. These individuals suffer disproportionally from health issues, job loss, a lack of stable housing, high utility costs, substance abuse, and homelessness. In addition to medical care, these individuals often critically need access to community social sector organizations that provide a distinct and complementary set of services, such as housing, food services, emergency utility assistance, and employment assistance. These services are just as vital as healthcare services to these individuals' long-term health and well-being, with data suggesting that 80-90% of health outcomes can be attributed to factors beyond direct medical intervention. This book proposes a novel approach to the coordination of medicine and social services through the use of people, process and technology, with the goal being to streamline coordination