The concept of systems of care originated with the emerging need to improve the quality of services and supports for children and youth with complex and multifaceted needs. Most children requiring systems-based care have significant mental health conditions associated with impairment of daily functioning within the home, family circle, school, or the community. Systems of care require significant infrastructure supports that provide a wide array of care services from a broad range of healthcare providers. Community, state, federal, and private agencies coordinate complex service provision across a broad swath of stakeholders. While care is largely standardized, it is important to remember the individual needs of each child presenting for care. The COVID-19 pandemic significantly disrupted access to care systems and care delivery within those systems including foster care placement, inpatient mental health units, immigrant and migrant facilities, and juvenile justice placements. Careful consideration to the unique vulnerabilities and challenges faced by children in these systems-based care environments is needed to reduce harm and optimize holistic health.