Downloadable software that utilizes machine learning for providing analytics regarding historical healthcare claims data, identifying at-risk populations for health interventions, optimizing health care choices and interventions, analyzing healthcare utilization, analyzing financial impact of social, behavioral and health-based interventions and support, tracking health markers in patients, and identifying opportunities for increasing healthcare engagement; downloadable software for integrating healthcare information and data between Medicaid care providers and community health providers, identifying at-risk individuals for community-based social, behavioral and health-based interventions, and increasing utilization of non-emergency healthcare services; downloadable software for automating care pathways and generating suggested actions for community-based care teams, based on algorithmic development; downloadable software for running risk models on health claims data, stratifying patients into risk tiers, and identifying appropriate interventions to increase health engagement and health markers; Downloadable software for users to engage in virtual social, behavioral and health-based interventions; downloadable software for community-based field teams consisting of community health workers, pharmacists, social workers and medical assistants to text message, video chat, coordinate in-person visits with patients, and coordinate overall social, behavioral and health based interventions and support for Medicaid recipients