Projects: Collaborate.Health

Advancing Population Health on Martha’s Vineyard

Integrating population health and clinical care on Martha’s Vineyard

Using Mobile Technologies to Improve Health Outcomes
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Island Health Care, or IHC, is a federally qualified health center located on Martha’s Vineyard – an island that is about four miles off the coast of southeast Massachusetts. IHC provides comprehensive care to island residents, including primary care services, dental and oral health care, and mental health services. A population of 20,000 island residents for most of the year, The Vineyard is home to 200,000 summer residents. The goal of IHC is to provide high-quality healthcare to every island resident, regardless of insurance status or income.


Because public health is often disconnected from the health care system and public health nurses (PHNs) and community health workers (CHWs) are siloed connecting patients to the resources they need is often a struggle. Major priorities for Island Health Care are to integrate population health activities carried out by the community health workers and public health nurses with primary care, facilitate  patient access to community resources, and strengthen the communication between primary care practitioners and population health workers. 


To date the PHNs and CHWs of IHC have been utilizing paper-based forms and tracking documents with clients, making a transition to mobile technology for their field-based interactions both exciting yet challenging. IHC will need to adjust workflows to use mobile technology effectively. On the positive side, preparing for digital information capture with an app provides an opportunity to modify and improve both workflow and process.


Using CommCare’s open source platform, the graduate-student consulting  team developed a mobile application that allows PHNs and CHWs to easily register, track, and collect population health data on patients across Martha’s Vineyard. The app will break down the silos that have hindered effective communication and integrate health assessments, mental health and substance use screenings, follow-up care, referrals, and more allowing for better health and continuity of care of individuals and the population.


When implemented, the IHC  mobile application will allow CHWs and PHNs to conduct patient assessments and follow-ups more easily, share case data among their teams, and initiate more referrals for patients in need of advanced care or wraparound services. Since the app is provider-facing, it will facilitate and streamline the everyday workflows of CHWs and PHNs while protecting patient privacy and confidentiality. We envision that our application will not only allow these frontline workers to perform their jobs with greater ease and efficiency, but also increase access to care for Martha’s Vineyard’s most vulnerable residents. We hope that our mobile technology solution advances and promotes continuity of care for IHC patients across the island and improves health outcomes for all.  

Project Timeline

This project took six months to complete from kick-off meeting to presentation of final deliverables. Click the button below for a detailed timeline.

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The IHC Project Team

Eilisha Mandanhar, Ashley Trickett, Caroline Eason, Laura Housman, and  Hannah Henrikson