The Healthy Greater Newark Accountable Care Organization (HGN-ACO) is a group of Newark-area hospitals, primary care practitioners, specialists, behavioral health providers, and community organizations committed to improving the quality of care and health outcomes for Newark residents who are enrolled in Medicaid. Phase One of the ACO’s care coordination work is focused on high utilizing Medicaid patients who reside in the South and West Ward zip codes of 07103, 07108, and 07112. A core strategy of the HGN-ACO is the design, implementation and managment of a health-information exchange as a technology solution that provides regional population health analytics. The ACO’s other core strategy is the design and testing of a high-risk diabetes pilot. This care coordination pilot is designed to serve diabetic patients between 30-50 years of age with comorbid mental health and substance use diagnoses and high advoidable Emergency Department and/or Inpatient utilization.