Development of ICT-Based Comprehensive Health and Social-Needs Assessment System to Enhance Person-Centered Community Care.

We developed a comprehensive health and social-need assessment system to evaluate the diverse needs of elders with chronic illnesses in the community and to enhance the connection of their needs to health and social services. A comprehensive needs-assessment tool and profiles were integrated into the ICT system. We found that care managers could assess elders' needs comprehensively and connect those needs to suitable health and social services systematically.