A regional health plan was challenged by its board to adapt a community-based, neighborhood model to care for more complex, high-need, high-utilization, underserved populations, including ABD, LTSS, LTC, SMI, and IDD members as well as dual eligibles and foster children. The health plan needed to successfully demonstrate its ability to identify and manage risk, coordinate care, ensure access, deliver outcomes, and decrease costs for various member cohorts.