Patient populations with mental health and/or addictive disorders have substantially higher medical costs and poorer outcomes than those without. Unmet social needs (housing, transportation and social connection) are a common cause of deficient outcomes and an obstacle to cost-efficient care to this population. Successful treatment requires addressing the whole person, including their medical, behavioral health and social needs. Applying a population health management approach requires acquiring, aggregating and fully utilizing data from multiple data sources across all these areas. In this session, attendees will see how aggregated data can be presented in easily digestible dashboards and sorted by illness or healthcare gap down to the individual patient level for use in care management and care coordination. This session will also outline infrastructure and workforce training needs as executed in a pragmatic, real-world care delivery system in Missouri.