In 2015, the Washtenaw Health Initiative was selected to coordinate one of five Community Health Innovation Regions (CHIR) in Michigan’s State Innovation Model demonstration, funded by the U.S. Center for Medicare and Medicaid Innovation. The Livingston/Washtenaw CHIR would work to improve health by addressing upstream social and economic factors. With backbone support from CHRT, the local CHIR launched its demonstration in August 2017. The CHIR provides wraparound care coordination for frequent ED patients by linking these patients to community health, mental health, and human service agencies. Potential participants are identified in one of two ways: provider referrals or a predictive model. A randomized controlled trial will measure outcomes. CHRT staff help coordinate care with the 12 local agencies participating in the pilot: Avalon Housing, Corner Health Center, Home of New Vision, Jewish Family Services of Washtenaw County, Integrated Health Associates (IHA), Livingston County Catholic Charities, Livingston County Community Mental Health, Michigan Medicine Complex Care Management Program, Packard Health FQHC, St Joe’s Complex Care, Washtenaw County Community Mental Health, and the Washtenaw Health Plan.