HIBC Initiatives

Care Coordination

Health care isn’t just what a patient receives at a hospital or clinic. Health care can be extremely confusing, complex and, thus, inaccessible; particularly for people living with chronic illnesses (such as diabetes, high blood pressure, and high cholesterol). These patients often require significant resources to manage their illnesses. To fully address a person’s health needs so he or she can live the healthiest life possible, community resources, social services, mental health care and the creation of a support network that extends into that person’s daily life is necessary.

More Resources for Patients with Chronic Illnesses
The goal of care coordination is to make high-quality referrals and transitions that ensure the patients’ needs and preferences for care are understood and shared by providers, institutions, patients, and families as patients move from one health care setting to another. The HIBC model views care coordination from the perspective of a patient centered medical home (PCMH) and the major external providers and organizations with which a PCMH must interact.

The HIBC Care Coordination initiative consisted of two collaborative tracks involving a public/private partnership between Federally Qualified Health Centers (FQHC) and private practice providers. Care Coordinators and Patient Navigators are embedded in the FQHCs as part of the PCMH team-based care model. A private practice care coordination service provides access to Care Coordinators and Health Coaches for physician practices as an external service component of the PCMH team-based care model. The collaboration between the two approaches has provided a rich learning environment for the Clinical Transformation Steering Committee regarding standards of care, patient risk identification, policies, procedures, use of health information technology and sustainable business model development. 

HIBC and three Community Health Centers (CHCs)—Bay Clinic, Inc., Hamakua Health Center, and West Hawaii Community Health Center—worked together to build the first care coordination programs on Hawaii Island. These programs targeted a few hundred patients identified as having the greatest need due to chronic illnesses and social circumstances.

Hawai‘i Island Care Coordination Services (HICCS) facilitated the integration of complex Care Coordination services in partnership with primary care practices. By partnering with HIBC and collaborating with the community health centers, HICCS has been highly effective in reducing avoidable hospitalizations and improving medical compliance.

The following are HIBC’s key accomplishments:

    Implemented care coordination services island wide.
    Formed a Clinical Transformation Steering Committee.
    Developed a target population registry, which includes 529 patients receiving care coordination services from partner agencies.
    Established care networks and communication channels which allowed care teams across regions to address care coordination challenges for highly complex patients.
    Conducted four community based learning collaboratives which brought community leaders together for a day of learning and building Beacon neighborhoods.
    Implemented data collection and reporting methodology following HRSA Health Disparities Collaborative guidelines, in the absence of a functional health information exchange.
    Installed in-home wireless health information technologies in 30 homes island wide.


Bay Clinic Bay Clinic, Inc. is a network of eight community health centers serving East Hawaii’s families since 1983.

Hamakua Health Center Hamakua Health Center, Inc. serves the Big Island of Hawaii by providing accessible, affordable, quality health care and educational services with an emphasis on individual and community wellness.

West Hawaii Community Health Center offers quality, comprehensive, and integrated health services accessible to all regardless of income.

Hawai‘i Island Care Coordination Services, LLC (HICCS), founded in a joint venture between West Hawai‘i Home Health Services and Ho’okele Health Innovations, HICCS facilitates the integration of complex Care Coordination services in partnership with primary care practices.

Lessons learned:

    1) Rapid results depend on leadership alignment and commitment to a common vision across the community.

    2) Communication pathways build upon trusted relationships must be in place prior to any electronic exchange of information.

    3) System development and growth depend on collaboration that is encouraged and perceived as valuable.

    4) In a rural community with scarce mental health resources, patients need more intensive one-on-one support and coaching then expected.

    5) Leaders should begin with the end in mind. Identify metrics and an evaluation strategy for interventions prior to implementation.