State of the Field

Cross-Sector Data Sharing to Create Healthier Communities

Karis Grounds, VP of Health and Community Impact

Disclosures

I have no conflicts of interest to disclose.

Objectives

• Understand the current state of field for healthcare and social services

and value in addressing health equity through cross-sector collaboration

and data sharing.

• Recognize successes and challenges with redesigning health and social

systems through shared language, interoperability and data integration.

• Describe the return on investment from a micro, mezzo, macro level for

true community impact.

• Free, 24/7 service, 3-digit dialing code

• Access to community, health, social and disaster

services

• Tailored programs take the client beyond just a

referral—movement towards Navigation

211 San Diego/Imperial

• Systems change that fosters true collaboration

across networks

• Moving towards person-centered interventions

and interactions across healthcare and human

services

• Goal is to improve health and wellness for

individuals and populations

Community Information Exchange

State of the Field

Proliferation of

Technology

Public Awareness of the Social

Determinants of Health

Evolving Funding Environment

Person-Centered Care

Cross-Sector

Collaboration

Research and

Policy Advocacy

State of the Field

Social Influences Greatly Impact Health

Public Awareness of the Social Determinants of Health

Hood, CM, Gennuso, KP, Swain, GR, & Catlin, BB. (2015). County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine.

Person Centered Care

Innovations in technology have

fundamentally transformed how

people consume, use, and share

information.

Proliferation of Technology

Cross-Sector Collaboration

Increase in cross-sector collaboration to break down

silos and foster clinic-community linkages to better

understand and serve the needs of people who

overlap systems of care.

Evolving Funding Environment

Increase in efforts to measure whether investments in health care and social interventions impact a person’s health and well-being relative to the investment.

Research and Policy Advocacy

Data has been instrumental in shaping public policy to

reinforce cross-sector collaboration and the role of social

determinants of health on quality of life.

National research and collaborative network initiatives

provide an avenue for local collaborative to examine their

impact on population health across

• socioeconomic class,

• demographics, geographic areas, and

• patterns and trends that influence human behavior.

What is a Community Information Exchange?

A community information exchange (CIE) is an ecosystem comprised of

multidisciplinary network partners that use a shared language, a resource

database, and an integrated technology platform to deliver

enhanced community care planning. Care Planning tools enable partners to

integrate data from multiple sources and make bi-directional referrals to

create a shared longitudinal record. By focusing on these core components,

a CIE enables communities to shift away from a reactive approach to

providing care toward proactive, holistic, person-centered care.

Technology Platform and Data Integration

Technology software that integrates with other platforms to populate an individual record and shapes the care plan. Partners access the system. System features include care team communication feeds, status change alerts, data source auto-history and predictive analytics.

Shared Language (SDoH)

Setting a framework of shared measures and outcomes through 14 Social Determinants of Health Assessments and a Risk Rating Scale: Crisis, Critical, Vulnerable, Stable, Safe, Thriving.

Bidirectional Closed Loop Referrals

Updated resource database of community, health, and social service providers. Ability to accept/return referrals and to provide outcomes and program enrollment.

Community Care Planning

Longitudinal record with a unified community care plan that promotes cross-sector collaboration and a holistic approach.

Community Information Exchange (CIE) Overview

Network Partners

Collective approach with standard Participation Agreement, Business Associates Agreement and participant consent with shared partner governance, ongoing engagement, and support.

Community Information Exchange Partners

Healthcare SectorHealth Plans

Hospitals

Emergency Medical Services

Health Centers

Health Information Exchange

Behavioral Health

Public Health

Network

Partners

Social Services Sector

Housing

Multi-Service

Human Development and Aging

Legal

Employment

Nutrition

Network

Partners

Government SectorNetwork

Partners

Cities

Fire Departments

County of San Diego Health and Human Services

Primary Care and Prevention

Housing Stability Health Management

Nutrition & Food Security

Legal & Criminal Justice

Safety & Disaster

Transportation Employment Development

Personal Care & Household

Goods

Financial Wellness and

Benefits

Education & Human

Development

Social & Community Connection

Activities of Daily Living

Utility & Technology

14 Domains: Risk Rating Scale

CRISIS CRITICAL VULNERABLE STABLE SAFE THRIVING

KNOWLEDGE AND UTILIZATION

BARRIERS AND SUPPORTS

IMMEDIACY

Shared

Language (SDoH)

Hub for social and health sites and providers

Resource Database and Bi-directional Referrals

• Shared taxonomy language for

referrals (AIRS)

• Dedicated resource staff

• Standards to listings and

requirements

• Inclusion/Exclusion Criteria

• Linked to health conditions

• Tracks resource availability and

unmet needs

• Shared taxonomy language for

referrals (AIRS)

• Dedicated resource staff

• Standards to listings and

requirements

• Inclusion/Exclusion Criteria

• Linked to health conditions

• Tracks resource availability and

unmet needs

Bidirectional

Closed Loop Referrals

Technology Platform

ETL

API

Housing (HMIS)

EMS

API

Extract Transform Load1. Reads data from a database

2. Converts the data for the new database

3. Loads into the new database

MDMMaster Data Management• Detects and merges duplicate records

• Ensures the accuracy, completeness, and consistency of

multiple domains of enterprise data

API

shared client

record

CIE

File upload

Alerts

Single Sign on

Jail

Food

!

Technology

Platform and Data

Integration

Client Profile• Demographic and important information about the client

Domains• Examples like Housing, Food & Nutrition, • Categorization of Needs (SDOH) & Risk Level• Shared Assessments and Values across agencies

Care Team• Case Managers working with client across agencies• Contact Information

Referrals & Program Enrollment• Agencies or programs client is referred• Connection to Services

Alerts• Notification of emergency services & jail• Ability to notify Care Team Members of changes

Feed• Ability to communicate like Twitter to other Care Team members

CIE Shared RecordCommunity

Care Planning

Benefits of a CIE

Potential Value and

Alignment

Reduction on healthcare utilization

Improvement in social and health

wellness

Better Health Outcomes

Evidence for Success

Improved Efficiencies in

connection and relationship to

resources

R e c o r d

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A d v a n c e Q u a l i t y

o f L i f e

A d d r e s s i n e q u i t i e s

( R a c e , G e n d e r , C y c l e

o f P o v e r t y )

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Questions?