Many barriers to healthcare exist due to ongoing psychosocial factors. Providers and their staff, case managers, social workers and others may refer patients in need of supportive services to the Population Health team via the SOHO HEALTH Referral Line. Community Healthcare Coaches will be assigned to work with referred patients to identify and address areas of need. The Population Health Team coordinates a variety of services including; transportation to medical appointments, securing food and shelter, energy assistance, benefit eligibility and entitlements and obtaining adaptive equipment. By aiding patients to resolve these issues, we optimize their ability to focus on their health, thereby improving patient outcomes.