ArticleApplied clinical informatics2020
Empowering Caseworkers to Better Serve the Most Vulnerable with a Cloud-Based Care Management Solution.
Article in Applied clinical informatics, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
7 citing papers in PubMed, 1 synthesis or guideline pooled it, 16 citations in OpenAlex.
- A Systematic Review of Electronic Community Resource Referral Systems.American journal of preventive medicine · 2023Pooled it
- Leveraging Artificial Intelligence to Inform Care Coordination by Identifying and Intervening in Patients' Unmet Social Needs: A Scoping Review.Journal of advanced nursing · 2025Article
- The Future of the Psychiatrist.Psychiatric research and clinical practice · 2025Article
- Artificial Intelligence Applications in Health Care Practice: Scoping Review.Journal of medical Internet research · 2022Article
- The Perceived Impact and Usability of a Care Management and Coordination System in Delivering Services to Vulnerable Populations: Mixed Methods Study.Journal of medical Internet research · 2021Article
- Precision Medicine, AI, and the Future of Personalized Health Care.Clinical and translational science · 2021Review
- How do nurses work in chronic management in the age of artificial intelligence? development and future prospects.Digital healthArticle
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
11 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundCare-management tools are typically utilized for chronic disease management. Sonoma County government agencies employed advanced health information technologies, artificial intelligence (AI), and interagency process improvements to help transform health and health care for socially disadvantaged groups and other displaced individuals.
objectivesThe objective of this case report is to describe how an integrated data hub and care-management solution streamlined care coordination of government services during a time of community-wide crisis.
methodsThis innovative application of care-management tools created a bridge between social and clinical determinants of health and used a three-step approach-access, collaboration, and innovation. The program Accessing Coordinated Care to Empower Self Sufficiency Sonoma was established to identify and match the most vulnerable residents with services to improve their well-being. Sonoma County created an Interdepartmental Multidisciplinary Team to deploy coordinated cross-departmental services (e.g., health and human services, housing services, probation) to support individuals experiencing housing insecurity. Implementation of a data integration hub (DIH) and care management and coordination system (CMCS) enabled integration of siloed data and services into a unified view of citizen status, identification of clinical and social determinants of health from structured and unstructured sources, and algorithms to match clients across systems.
resultsThe integrated toolset helped 77 at-risk individuals in crisis through coordinated care plans and access to services in a time of need. Two case examples illustrate the specific care and services provided individuals with complex needs after the 2017 Sonoma County wildfires.
conclusionUnique application of a care-management solution transformed health and health care for individuals fleeing from their homes and socially disadvantaged groups displaced by the Sonoma County wildfires. Future directions include expanding the DIH and CMCS to neighboring counties to coordinate care regionally. Such solutions might enable innovative care-management solutions across a variety of public, private, and nonprofit services.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.