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Care coordination can improve patient outcomes, increase continuity of care, and reduce healthcare utilization. This study explores the effectiveness and limitations of care coordination as a strategy for meeting vulnerable patients’ needs. The study team conducted a qualitative, multi-site, collective case study of four sites providing care coordination for vulnerable and marginalized populations. Data were gathered via individual patient interviews ( n  = 69) and staff focus groups (82 participants) and analyzed using a matrix template to code data and identify common themes. Addressing patients’ needs required coordination across behavioral, medical, and social service providers. This was most effective when it included social needs and built on trusting relationships between patients and staff. However, sites faced shared challenges from systemic barriers that limited their effectiveness. For vulnerable and marginalized populations, evidence-based care coordination can only address some needs, and benefits are often undermined by deeply entrenched structural deficits. Future care coordination programs must include an assessment of structural barriers and incorporate concurrent efforts to address them.

Systemic barriers to care coordination for marginalized and vulnerable populations