Community Information Exchange: Addressing Social Determinants of Health through Person-Centered Care William York Karis Grounds Executive Vice President VP of Health and Community Impact 211 San Diego 211 San Diego
211 History 1970 Information and Referral (I&R) is the art, science and practice of bringing A program of United Way people and services together. 1997 When individuals and Atlanta launched the first 211 families don't know where to turn, I&R is there for them.
SAN DIEGO • 5th largest U.S. County • 18 municipalities • 18 tribal nations • 42 school districts • Region is very diverse: • Over 100 languages • Large military presence • Largest refugee resettlement site in CA • Busiest international border crossing in the world
What We Know Social influences greatly impact health
State of the Field Awareness of the Evolving Funding Proliferation of Social Determinants Environment Technology of Health Person-Centered Cross-Sector Research and Care Collaboration Policy Advocacy
CIE Timeline
CIE: ROI Year 1: Homeless Cohort Analysis 26% 44% EMS Transports Post CIE Remained in housing enrollment improvement reduction Year 2: Senior Cohort Analysis
CIE: Social Navigation Year 1 Outcomes: 2016-2017 Shared Goal: Assist in the transition from hospital discharge to home by assessing and connecting to social Hospital Readmission Rates determinants of health resources through electronic referrals from 35.0% EHR to 2-1-1 Health Navigators 30.0% 30.0% 25.0% Measures: 20.0% Percent of individuals • 15.0% readmitted into hospital 9.6% Improvement on shared Risk • 10.0% Rating Scale 5.0% Patient Satisfaction • 0.0% Self-Efficacy • 211 Patients Comparison Group
Person Centered Model
Community Information Exchange Network Partners Shared Language (SDoH) Bidirectional Closed Loop Referrals Collective approach with standard Participation Setting a Framework of shared measures Updated resource database of community, health, Agreement, Business Associates Agreement and and outcomes through 14 Social and social service providers. Ability to participant consent with shared partner Determinants of Health Assessments and a accept/return referrals and to provide outcomes governance, ongoing engagement, and Risk Rating Scale: Crisis, Critical, Vulnerable, and program enrollment. support. Stable, Safe Thriving Community Care Planning Technology Platform and Data Integration Longitudinal record with a unified community care Technology software that integrates with other platforms to plan that promotes cross-sector collaboration and a populate an individual record and shapes the care plan. holistic approach. Partners access the system. System features include care team communication feeds, status change alerts, data source auto-history and predictive analytics.
Community Information Exchange Partners Network Partners
14 Domains of Social Determinants of Health Shared Language (SDoH) Primary Care Health Nutrition & Food Financial Activities of Social & Housing Stability Management Security Daily Living Community and Prevention Wellness and Benefits Connection Legal & Criminal Safety & Disaster Utility & Transportation Education & Personal Care & Employment Justice Technology Human Household Development Development Goods
CIE Risk Rating Scale Shared CRISIS CRITICAL VULNERABLE STABLE SAFE THRIVING Language (SDoH) IMMEDIACY Less than One 1-3 Day Adequate Nutritious Ability to M aintain Day Supply of Supply of Food Supply up to 30 Days Food Food Food Food KNOWLEDGE Some Connected to a Limited Know ledge Practices UTILIZATION Access FOOD & NUTRITION Number of Short Term to Buy and Healthy No Access or AND (Food Resources Prepare Eating Know ledge of Banks & Nutritious and Resources (CalFresh, WIC, Food Food Wellness Long-term and sustainable Supplemental) Pantry) access to nutritious foods and to support services to maintain access BARRIERS SUPPORTS Some Barriers (e.g. Lack No Barriers AND Access to Grocery Stores) and Limited Supports and (Supports to Food Preparation Lack of Transportation, Finances Limited Friend or Family and Finances) Supports FOOD INSECURE FOOD INSECURE FOOD SECURE WITH HUNGER WITHOUT HUNGER IN COLLABORATION WITH:
Food & Nutrition Shared Language (SDoH) Decisions over Nutrition Concern about Food Supply During the last 30 days, how often are clients What other basic needs do clients need to concerned about their food supply? How meet before they can address their nutrition often do they actually run out of food? needs? Primary Care 7% 45% of clients are often worried their Transportation food supply will run out 26% Housing Education & Human 24% of clients often 39% Development 2% actually run out of food during Utility & Technology the month 24%
Resource Database Hub for social and health sites and providers Bidirectional Closed Loop Referrals Shared taxonomy language for referrals (AIRS) • Dedicated resource staff • Regular updates made to resources • Standards to listings and requirements • Inclusion/Exclusion Criteria • Linked to health conditions • Tracks resource availability and unmet needs •
Technology Platform Technology Platform and Data MDM Integration Master Data Management Detects and merges duplicate records • API Ensures the accuracy, completeness, and consistency of Food • multiple domains of enterprise data CIE Jail API shared client record API EMS ETL ! Alerts Extract Transform Load Single Sign on File upload 1. Reads data from a database 2. Converts the data for the new database 3. Loads into the new database Housing (HMIS)
CIE Shared Record Community Care Planning 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
Partnership with County of San Diego Health and Human Services Bridge between CIE and ConnectWell Connect each other systems for following purposes: • Resource Database • Risk Rating Scale • Identify-Proofing • Referrals • Partnerships and Engagement with CBOs
2016 Collaborative: San Diego Community Health Needs Assessment TOP SOCIAL NEEDS TOP HEALTH NEEDS
Partnership with Health Information Exchange Short Term Goals : Present CIE data into the HIE • Single sign-on for platforms (CIE & HIE) • Research • Healthcare utilization and outcomes & social determinants of health • Long Term Goals: Present HIE data into the CIE • Explore bi-directional referrals & Master Patient Index • Create standards and best practices between HIE & CIE •
Driving Interoperability Patient identification • Consent management • Notifications and alerts • Data quality • Connecting All for Data provenance • Better Health & Wellness PHI and PII • Public health to primary care • Proper presentation summary • Closed loop referral system •
Fully Integrated Information Exchange Public Health Social Behavioral Medical Comprehensive Longitudinal Health Record C O O R D I N A T I O N Longitudinal Longitudinal Community Record Medical Record Connect/Communicate/Referrals Person ID System Legal/Consent
CIE: Toolkit Launch Download via PDF at www.ciesandiego.org CIE: Summit April 24-26, 2019 San Diego, CA https://ciesandiego.org/ciesummit2019/
Karis Grounds William York VP OF HEALTH AND COMMUNITY EXECUTIVE VICE PRESIDENT wyork@211sandiego.org kgrounds@211sandiego.org
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