Care coordination (CC) is a critical function in the healthcare system and is currently a national priority in the US. Improved CC help reduce avoidable hospital admissions and readmissions.

A CC system is a common platform where in all the care providers including patients interact with each other thereby sharing a common set of information and knowledge about a patient’s condition that will result in improved quality of care. This study reviews various frameworks and strategies in CC, and finds that most CC systems do not address the social and community service coordination dimensions of CC. This is especially important as there is an increasing move towards “aging at home” in the country. So this study also presents the design and implementation of a community-based CC system for elder-care. Specifically, the approach adopted in this study was to develop a Learning Community for service providers, so better communication and learning among providers would result in increased care coordination across healthcare, social, and community eco-systems in the area of elder-care.