A Transdisciplinary Approach to Healthcare Informatics Practice and Research: Implications for Elder Care with Poly Chronic Conditions

Population health management is to target subpopulation groups that have varying healthcare needs. In particular, health care for three categories of elderly patients overburdens the financial and workforce capacities of most communities. One category includes elders with multiple chronic illnesses, living independently. A second category includes elders with functional limitations requiring long-term assistance. Collectively, they comprise 2 to 5 percent of any community. A third category includes elders making transitions across the care continuum, such as moving from a hospital to a rehabilitative facility after surgery. Each patient category presents a unique population group, including common but varying healthrelated problems associated with aging. Thus, their complex needs reflect the design and implementation imperatives for optimizing resources and information exchanges required for enhancing coordinated care.