Providing downloadable software for community-based field teams to text message, video chat, coordinate in-person visits with patients, and coordinate overall social, behavioral and health care for Medicaid recipients; Providing downloadable software for integrating healthcare information and data between Medicaid care providers and community health providers, tracking community-based social, behavioral and health-based interventions, and increasing utilization of non-emergency healthcare services; Downloadable software for mobile phones, computers and wireless devices for use by community-health providers for booking and coordinating social, behavioral, and health-based interventions and support for Medicaid recipients; Providing downloadable software for mobile phones, computers and wireless devices for community-based field teams consisting of community health workers, pharmacists, social workers and medical assistants to text message, video chat, coordinate in-person visits with patients, and coordinate overall social, behavioral and health-based interventions and support for Medicaid recipients