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How Dimagi Enables CHWs to Care for Marthas Vineyards Highest-Need Residents - Dimagi

(From left to right) Kathleen Samways, Ashley Trickett, and Youxuan Wang of Island Health Care and Boston University presented a poster on their collaboration with Dimagi at the 2023 New England Rural Health Association Conference in Killington, Vermont

By James Wolff, Chief Medical Officer and Kathleen Samways, Chief Public Health Officer, Island Health Care

Many Americans don’t associate Martha’s Vineyard with poverty or healthcare access challenges, but according to 2020 U.S. Census figures, 8.8% of residents of the Massachusetts island live at or below the poverty line. 

Island Health Care (IHC), a federally qualified health center, was established to improve access to equitable, high-quality, affordable healthcare and resources for individuals and families —especially those who struggle with barriers such as geographic isolation, transportation, insurance coverage gaps, financial constraints, cultural and linguistic barriers, and limited access to specialist and pharmaceutical care. To address these health equity challenges, Boards of Health in Martha’s Vineyard provide public health nursing services through a contract with Island Health Care’s community health workers and population health nurses to provide care outside of traditional healthcare facilities. 

As the island’s year-round population continued to swell — it grew 24% between 2010 and 2020, according to Census data — so did the challenges in providing community care: biometric screenings, annual physicals, and new mother and baby well-visits, as well as behavioral health care and social services, outreach coordination and follow-up. To keep up with patient demands IHC needed digital tools and workflows to help them efficiently provide a variety of community based public health interventions.

While population health nurses and community health workers are finally receiving national recognition as a critical aspect of a strong, fully functional health care system, too often in the U.S., these workers aren’t served by existing technology ecosystems, and often lack digital tools to support their work. 

And because community health workers are often disconnected from traditional healthcare technology systems, such as EHRs and health information exchanges (HIE), conducting all needed screenings and ensuring appropriate follow-ups for at-risk patients becomes even more difficult. 

In 2022, graduate students at Boston University tackled this problem head-on, working together on Dimagi’s flexible, drag-and-drop platform, CommCare, to develop a tool that could support these community health workers in all aspects of their work. In April 2023, Island Health Care partnered with Dimagi to help further develop the existing solution created by the BU students. 

CommCare offers users an intuitive interface, with applications and features that can help community health workers improve data collection, case management, and reporting. The agile, configurable platform is equipped with flexible question formats (that can be tailored to home visits), case-based data collection fields (that can be easily viewed and updated); automated alerts/reminders, and more. 

Dimagi worked hand-in-hand with Island Health Care’s IT team to address its wish list and incorporate even more useful functionality into the already-successful tool:   

  • Omaha taxonomy’ workflow templates, which would allow clinicians to identify problems, select interventions, and measure progress over time. The Omaha workflow template linked to their existing in-house forms (previously, there was no single source for required documentation); 
  • Streamlined screening prompts for risk assessment (for diabetes, depression, and other comorbidities); 
  • Tracking of follow-up tasks and due dates; 
  • New clinician-centered logic trees (e.g., prompts for follow-up questions, such as screening for postpartum depression during newborn wellness visits. 

The CommCare application tracks identified problems for each patient and prompts users to plan and carr out relevant interventions to address them. Users can set due dates for interventions and care plan updates to ensure tasks are completed on time and nothing falls through the cracks.

Since implementing CommCare, Island Health Care has experienced consistent and improved documentation and time savings. CommCare collaboration tools have also eased data-sharing with Island’s partners, mainly Boards of Health within the Vineyard who rely on information and actionable insights to personalize intervention services. The new Omaha taxonomy also allows users to track healthcare concerns and outcomes in one place, improving follow-up care and helping to flag and treat conditions or address social determinants of health more effectively.

The Care Plan Summary allows public health workers to review screening results, interventions, and patient outcomes all in one place, enabling more informed patient care and service delivery. 

Using CommCare during home visits has also eased information sharing between clinicians and other care partners. If, for example, a nurse is conducting a wellness visit for a newborn baby in their home, CommCare prompts will remind the nurse to screen the home environment or ask about familial support networks. 

Moving forward, IHC’s goal is to have all Public Health Nurses and Community Health Workers adopt the Omaha protocol. CommCare will help the organization scale the protocol for new members and standardize operations across teams to create more efficiencies and care consistency. 

The authors would like to acknowledge the contributions of the full project team, including James Wolff and Kathleen Samways of Island Health Care, Ashley Trickett and Youxuan Wang of the Dukes County Case Management Investigation Team, and Lauren Fox, Braxton Perry, and Elaina Faust of Dimagi. 

To learn more about how Dimagi’s CommCare platform can be leveraged to empower Community Health Workers and Public Health Nurses in the United States, please contact



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