From 1993 to 1997, researchers at Wake Forest University School of Medicine sought to expand the clinical data management system of a community health center to form an information network involving the health center, two county hospitals and six key community/home health service agencies in the Winston-Salem, N.C., area.

Researchers hypothesized that the Community Care Coordination Network (which operated in a fee-for-service environment), would reduce rates of unmet service needs, emergency department use, hospitalization, total health care costs and acute care utilization, and would improve patient and caregiver quality of life.

The project was part of the Robert Wood Johnson Foundation (RWJF) Building Health Systems for People with Chronic Illnesses national program.

Key Results:

• Project staff developed the Community Care Coordination Network linking six community and home health care agencies and two hospitals to the Reynolds Health Center, the primary care site where the Community Care Database is housed.
• Some 602 people were enrolled in the intervention.
• Project staff developed the Community Care Database, which records patient data and suggests protocols for proactive care coordination and case management.
• Project staff developed the community care alert, which allowed events such as emergency department visits, hospitalizations or changes in an individual's functional status to be communicated throughout the network.

Key Findings:

• An evaluation conducted by project staff determined that the project did not significantly reduce the use of acute care.