Simplifying Complex Care Management: A Case Study

Community Health Center Network (CHCN) is a non-profit managed care organization supporting the health needs of the Bay Area’s most at-risk and underserved populations.

CHCN developed Care Neighborhood, a care management program focusing on the medical, social, and behavioral health needs of the most complex members in these communities. CareNote was the prototype care management platform. When CHCN was ready to scale up the program, they needed a new care management system that would meet their needs and minimize the challenges CareNote presented.

Through an initiative sponsored by Health 2.0’s Technology for Health Communities, CHCN was partnered with Welkin Health, a San Francisco-based digital health company. Welkin proposed building care management software for CHCN, designed specifically for patient support, to meet the needs of Care Neighborhood.

CHCN uses claims data to develop lists of members most at risk for poor health outcomes. Paramount to the success of the Care Neighborhood program are CHCN’s Community Health Workers (CHWs), who are embedded in the clinics with mobility throughout the community to create and build long standing, trusted relationships with patients. CHWs then focus care and advocacy work around a patient’s social determinants of health in order to positively influence health outcomes. By connecting patients to resources around transportation, housing, food, behavioral health, and medical care, the CHWs have improved the health status of these high-risk members.

The Challenge

Prior to Welkin, CHCN relied on a system called CareNote to support the needs of their Care Neighborhood program. An Excel workbook, CareNote was designed to meet four key criteria considered essential to effectively manage Care Neighborhood: Data integration, workflow management, enhanced communication capabilities, and scalability.

CareNote had useful functions. For example, it allowed the team to rapidly incorporate clinical feedback, which proved CHCN’s hypothesis that a care management system was needed to drive workflow for CHWs, but there were many challenges.

CareNote was extremely slow to load, making data integration less efficient. The system often crashed, wasting time and reducing productivity for users.

Lacking communication channels such as email and text message, CHWs were limited in how they engaged and followed up with patients, instead relying solely on phone calls and in-person visits. Care Neighborhood staff thought text messaging capability would enhance the ability to connect with patients.

CareNote was also not scalable, a major problem for CHCN who planned to scale the Care Neighborhood program and expand to more clinics.

CHCN needed a tool that was more sustainable. Care Neighborhood needed a system that would better support CHW and patient relationships, manage complex workflows, and scale the Care Neighborhood program across their network.

The Solution

Welkin configured their platform to better support Care Neighborhood’s key criteria―data integration, workflow management, enhanced communication capabilities, and scalability. The system would guide CHCN’s staff through their various workflows, while offering six channels for patient outreach, capturing all their data on one unified tool.

Welkin’s solution streamlined the program’s workflows, and seamlessly integrated all patient data from multiple sources, such as select clinic EHR and demographic information from the clinic, as well as CHCN’s claims database, onto one dashboard. The heart of the Care Neighborhood program, the CHW’s relationship with patients, were strengthened when aided by Welkin’s multiple communication channels. Welkin will also support CHCN as they scale Care Neighborhood to more of the communityAlameda County.

Welkin recently surveyed 13 platform users (10 CHWs, 2 Licensed Clinical Social Workers and 1 nurse) and discovered a high-level of user satisfaction:


CHWs struggled with CareNote’s unreliability and inconsistency—the system’s slow nature and frequent crashes hindered productivity. The prototype system was unable to unify and analyze patient data across a single tool or better CHW and patient relationships. CareNote lacked the utility to scale the Care Neighborhood program.

The data shows that implementing Welkin made CHWs’ jobs significantly easier to perform. The software set them up for success, improved the quality of their work, and was simple for new users to use. Welkin also proved more dependable and increased user productivity by eliminating system crashes and loading quickly. When Care Neighborhood’s CHWs can work efficiently and effectively, it ensures the program will be more successful at scale in achieving its primary goals—more patients reached, increased time with patients, reduced ER visits, and lower healthcare costs.

Programs like Care Neighborhood deliver vital healthcare and social services to populations with unique needs and circumstances. Though patient management can be complex, the tools used to improve relationships shouldn’t be. Innovative solutions for complex patient management helps organizations like CHCN make a significant impact in their communities.

Make your program more care-centric today.

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