Introduction: Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations. Methods: Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes. Results: Analysis indicates that care coordination has a positive impact on clients' sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery. Conclusions: This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

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Background Introduction Savic and colleagues have described integrated care as a "holistic care model" that encompasses individual medical, physical and mental health needs, and includes social issues and environment [1]. Place-based interventions (PBIs) are initiatives that use complex partnership networks to implement multiple-component interventions aimed at changing the social and physical environment within a targeted location. Such an approach to integrated care creates a coordinated approach between multiple healthcare providers such as primary care, social services and hospitals, and supports community services. The PBI approach both connects and aligns the different sectors and organisations [2]. Effective integrated care strategies for primary-secondary interface include factors such as communication and information exchange, interdisciplinary teamwork and shared care guidelines and pathways [3]. Integrated care is thus founded on the interconnectedness between social and health issues of an individual and communities. There are many approaches to the design and implementation of integrated care. A co-location model, through PBIs, is one of them. PBIs co-locate different services and activities such as legal, health, social and housing within the same physical space. The extant literature supports the PBI approach for several reasons. Firstly, it is local physical and social