Platforms for Community-Wide Care Coordination

Care Coordination ChallengeThis week on #hcldr we’re doing something we’ve never done before. On Tuesday October 28th at 8:30pm Eastern (for your local time click here) we will have a panel of guests online with us:

  • Katherine Kim, PhD, MPH, MBA (@kimkater): health informaticist, researcher and Associate Professor at University of California, Davis
  • Charles Boicey, MS, RN-BC, CPHIMS (@N2InformaticsRN): Enterprise Analytics Architect for the State University of New York, Stony Brook Medicine
  • Janet Freeman-Daily, MS, Eng (@JFreemanDaily): metastatic lung cancer epatient, former aerospace systems engineer, comoderator of LCSM Chat
  • Susan Hull, MSN, RN (@SusanCHull): nursing executive , founder and CEO of WellSpring Consulting
  • Anna McCollister-Slipp (@annamcslipp): diabetes epatient, co-founder of Galileo Analytics

This same panel will be presenting at the upcoming Workshop on Interactive Systems in Healthcare (WISH) 2014 which will be co-located with the American Medical Informatics Association (AMIA) Annual Symposium on November 15, 2014 in Washington, DC. The responses gathered in the #hcldr chat will be including their panel discussion!

Special THANK YOU to Janet Freeman-Daily for spearheading the effort to bring this unique opportunity to the #hcldr community. We are grateful to have this chance to contribute thoughts and ideas to this important panel discussion.

Blog post by Katherine Kim, Charles Boicey, Janet Freeman-Daily, Susan Hull and Anna McCollister-Slipp.

Community-wide care coordination (CWCC) is a process that integrates care teams, patients, family members, caregivers, and community resources, wherever they might be, in order to provide the best possible patient care and experience.  CWCC aims to improve healthcare by improving the experience of care, improving the health of populations, and reducing per capita costs of health care. CWCC recognizes how social, community and environmental determinants of health impact how individuals, neighborhoods and communities thrive and share accountability for care coordination.

Technology platforms to support CWCC are critical given the complexity of the task.  CWCC must consider  diverse users needs and digital literacy, a large number of health information sources, a wide variety of health information exchange and data sharing strategies, and conflicting cultural and political influences.  People participating in CWCC need a technology platform that allows them to share information and data easily and securely, enables interoperability between diverse electronic medical records systems and monitoring devices, facilitates time-efficient and accurate use by the care team members (who are often spread across several facilities), and offers affordable access to patients, carers and families, even those for whom Internet is not readily available.

Unfortunately, few if any such platforms currently exist.  A handful of studies of home telehealth and care coordination have shown promise in improving quality and costs.1,2   There are emerging frameworks that seek to define information technology needs as they relate to integrated care coordination.3,4  While stand-alone applications and systems may be in use for specific chronic illness populations, there are few established technology platforms for comprehensively managing integration of information, activities, and workflow, community-wide.

The patients most in need of care coordination are those with complicated, acute, or chronic conditions.  Some are already using digital medical devices, health apps, and/or electronic access to their health data.  However, these devices usually cannot communicate with each other or with digital health data systems used by care teams.5,6 Decision making and shared care planning is difficult, especially over time.

A non-systematic search found 24 commercially available systems that described themselves as offering technology for “care coordination” and “patient engagement.”  However, analysis conducted by a multidisciplinary team found that none of these systems fulfilled the necessary functions described in these frameworks.7  Of particular concern is the lack of attention to engagement that would enable patients, family members and caregivers to participate with care teams in decision-making and have shared accountability for health.  Thus, while technology solutions are emerging, there are few comprehensive technology platforms that can support CWCC across a range of care settings, and even less about effective means for meeting individuals’ needs and preferences.

#hcldr Chat Topic

The October 28 #HCLDR chat will explore the challenges of “Platforms for Community-Wide Care Coordination.”  The chat topics correspond to questions that will be covered at the Workshop on Interactive Systems in Healthcare (WISH) 2014 which will be co-located with the American Medical Informatics Association (AMIA) Annual Symposium this November:

  • T1: What are the most important challenges patients, family members & caregivers face in coordinating care?
  • T2: What challenges do care teams (clinicians, lay health workers, managers) face in coordinating care?
  • T3: What are examples of where social media and other technologies have supported care coordination?
  • T4: How can social media & other technologies help coordinate care for publicly insured, rural & other underserved communities?


  1. “Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.” Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, et al. Telemedicine and e-Health. 2008;14(10):1118-26.
  1. “Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings.” Baker LC, Johnson SJ, Macaulay D, Birnbaum H. Health Affairs. 2011;30(9):1689-97.
  1. “Defining and measuring integrated patient care: promoting the next frontier in health care delivery.” Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Med Care Res Rev. 2011;68(1):112-27.
  1. “Health Information Technology to Support Care Coordination and Care Transitions: Data Needs, Capabilities, Technical and Organizational Barriers, and Approaches to Improvement.” Samal L, Hasan O, Venkatesh AK, Volk LA, Bates DW. National Quality Forum.  (2012).
  1. “Health apps ‘useless’ says health app expert.” Hall M. Sunday Morning Herald. (10/9/2014).
  1. The Grim Reality of Digital Health Today.” McCollister-Slipp A. Huffington Post (10/14/2014 ).
  1. Kim K. Unpublished.

Image Credit

UC Davis Betty Irene Moore School of Nursing


  1. […] Chat will tackle this topic, Platforms for Community-Wide Care Coordination, in their next chat on Tuesday, October 28, at 8:30 PM Eastern […]

  2. […] The panel for WISH/AMIA – on the topic of Community-wide Care Coordination […]

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