Care Transitions Intervention for Kaua'i


During this seven month engagement MataiNet provided management and technical support to Kauai Agency for Elderly Affairs (KAEA) to assess various challenges and institute improvements in client intake and tracking processes. The agency was challenged by slow client response times and occasional lost or misfiled client information, and needed assistance to identify and implement improvements. In addition, KAEA had received a grant for Care Transitions Intervention (CTI) and sought assistance to incorporate tracking of patient services into their processes and facilitate efficient grant reporting.


After completing a review of current processes and systems, MataiNet presented recommendations for changes to improve efficiency and quality. The client accepted all recommendations and extended the engagement to include guidance and implementation services. We also developed process guidance for support of the CTI grant and created tools to support efficient patient surveys and analysis.

Outcomes and Innovations

  • A standardized client intake form improved the agency’s ability to serve
  • Integrated client intake form into MIS system to eliminate need for paper and manual tracking processes
  • Tracking reports allowed the organization to monitor performance across all programs
  • Results of the CTI project demonstrated dramatic reductions of readmissions

Example Artifacts


MataiNet led the team through an introspective method to understand existing processes, consider improvements, evaluate options, choose experiments, assess results and repeat. Subsequently we led the effort to integrate improvements with the organization’s MIS/IT platform.


  • MS Word, Excel, PPT, Project, Visio, and Access
  • Synergy SAMS, BeaconIR, Omnia MIS suite