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Community Health Leaders Share Their Progress on Integrating SDoH Data into Healthcare

April 10, 2018
by Heather Landi
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Community-based organizations that seek to address their clients’ complex social needs, including assistance with health care, nutrition and housing, often need to separately log onto multiple systems and complete manual processes that require redundant information collection and other inefficiencies. However, many community-based organizations are advancing forward in their efforts to use health IT to collect and integrate social and behavioral health data.

These efforts were outlined during a panel of community health leaders at the 2018 State Healthcare IT Connect Summit in Baltimore last week. The panelists, who included executive leaders at community-based organizations and policy leaders at the Office of the National Coordinator for Health IT (ONC), discussed ongoing efforts to leverage technology to more effectively integrate health and social determinants of health data in order to address the complex social needs of patients.

In Northern California, the Redwood Community Health Coalition (RCHC) is making strides to leverage technology to better assess and address social determinants of health for populations with complex needs in its communities. RCHC is a network of 17 community health centers, with over 65 sites in Marin, Napa, Sonoma and Yolo Counties. Formed in 1994, RCHC’s mission is to improve access to and the quality of care provided for under-served and uninsured people in four counties, according to its website.

Teresa Tillman, chief operating officer at RCHC, said the organization operates as an HRSA (U.S. Department of Health and Human Services Health Resources and Service Administration) Health Center Controlled Network and supports health centers in four areas—health IT implementation and Meaningful Use (MU), data quality and reporting, health information exchange (HIE) and population health management and quality improvement. “We operate a small, private HIE to help our health centers to have pathways to engage in HIE, mostly for care transitions, so the health centers can talk with hospitals and help patients transition from acute care and back to primary care.”

“Community health centers have been dealing with social determinants of health for a long time. We have people that are working that are certified enrollment counselors, so they help patients to connect to food, so that type of work is not new for a health center. We also report a lot to the feds (federal government) already, such as housing, veterans’ status, employment status, that’s not new. But what we’ve seen in the last three or four years is an impetus to do this in a more standardized way,” Tillman said.

As an example, RCHC has been working to standardize how the health centers in its network collect data on patients and assess their social needs. RCHC worked with its health centers to streamline these efforts by getting all the center’s medical directors to agree to use one assessment platform, the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PREPARE) tool developed by the National Association of Community Health Centers (NACHC). The PREPARE tool consists of a set of national care measures as well as optional measures for community priorities.

“We, as a coalition, we provided technical assistance to the health centers to build questions into their EMR (electronic medical records) systems, so that we all ask the questions in the same way. And, we’re assisting them with what the workflows look like. We, as a coalition, aggregate that data up, working in partnership with managed care plans, to understand what’s coming down the pike. We want the health plans to partner in this journey, as the health plans have data to report up to the state,” she said.

Tillman said RCHC is currently working with managed Medi-Cal (Medi-Cal being California’s version of Medicaid) providers to bring in claims data. “From a practical standpoint, we need to understand what happens to the patient when they leave the health centers, such as if they are referred to housing, so we can build that web-based application to empower patients and we can see where they were referred and what the community resources are in that area.”

On the East Coast, the Camden Health Coalition pushes forward on a number of innovative programs to deliver better health care to vulnerable citizens in one of the poorest cities in the country, Camden, N.J. The Camden Coalition was founded by family physician Jeffrey Brenner, M.D., in 2002 as a breakfast group for local healthcare providers, and it quickly became focused on identifying and engaging the community’s residents with the most complex health and social needs and creating new models of care to shift costs and improve outcomes. The organization now has more than 100 staff members and 31-member organizations from across Camden.

The organization uses coordinated, data-driven, and patient-centered approaches—including addressing needs that have traditionally been considered “nonmedical,” such as addiction, housing, transportation, hunger, mental health, and emotional and educational support.


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