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?