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.
“Our care management department works with patients in Camden that are complex, clinically and socially, and work to link those issues together in the hopes of providing better care and reducing unnecessary hospitalizations, Abigail Fallen, senior program manager, health information exchange and data security at the Camden Health Coalition, said during the panel discussion. "We have a large data shop and we take data from different sources that are not linked in order to link them together and to identify trends that are driving patients to multiple hospital stays." And, she adds, "Our data tells narratives about our patient population.” The organization’s legal and advocacy departments leverage that data to push legislative initiatives to improve population health in Camden, and in similar populations throughout the state, she said.
The Camden Health Coalition stood up its own health information exchange (HIE) eight years ago and Camden Coalition staff use data from the HIE to better identify individuals eligible for enrollment in the Coalition’s intervention programs. While the HIE initially brought in clinical data from healthcare providers, HIE participants now include hospitals, primary care practices, laboratory and radiology groups as well as social service organizations, correctional facilities, and other licensed health care facilities and providers.
Pointing to how the organization has evolved and expanded the data that it brings into the HIE, Fallen said, “We have a “Housing First” initiative that uses housing data that we integrate with clinical data to help advocate for the patient, if they meet certain criteria, to get them into housing. The idea of housing first is to get them into a home and then address their needs, and that stabilizes them. Previously, in New Jersey, a patient had to stabilize themselves prior to housing.”
The Camden Coalition also developed its own platform, called My Camden Resources, that helps to connect Camden County residents with non-profit and social services. The platform is an up-to-date database of direct services available to Camden County residents for free or reduced cost, and the database is powered by the national platform Aunt Bertha. The platform was developed by the Camden Coalition of Healthcare Providers in 2016 in response to a community need to move beyond the traditional binder of local resources and to replace the manual work related to care planning, Fallen said.
“We’re now at a point that we’re looking at how we integrate and link the My Camden Platform into our HIE, so that users have one platform that they can go into from an end user perspective,” she said.
Ongoing Challenges to SDoH Data Integration
The panelists were asked what their ongoing challenges have been with integrating social determinants of health data and leveraging IT and technology in these efforts, especially in an environment where the healthcare payment and policy landscape is rapidly evolving.
“Interoperability is a big issue,” Tillman said. “Our challenge is that counties are behind and counties are just trying to figure out their own IT infrastructure in order to be able to connect primary care to social service agencies, which are often county [organizations]. We know what their standards are, we’re trying to mange to those standards, but until there is a dollar behind it, there’s the practical challenge of having reimbursement for some of this work. We’re working through that issue through grants.”
Fallen said, “We’ve struggled to find what technology should be, and we’re creating our own toolbox right now; we take different data sets and link them together for patients, and it is resource intensive. There is no one technology solution for that, for looking at housing data, school district data, etc.”
She said there are currently multiple regional HIEs in New Jersey working together to create a state-level platform to access data, such as registry information and prescription data. “So, rather than reinventing the wheel and having multiple interfaces, we’re working to create a state-level HIE where that data would sit. This is a large project and we have to bite one piece of it at a time. The reality is, healthcare continues to change, and when you begin to think that you understand the theme, then a curve ball comes in.”
Fallen continued, “We’re doing innovative work, but it’s taking a long time. It’s a lot of relationship building. We have a variety of partnerships, and we have some that it’s taken much longer than we wanted it to be, but we certainly go back to that table and have conversations again. You have to get back to the framing of it and why you’re trying to do it.”
She noted the organization’s “Faith in Prevention” program to engage Camden faith-based organizations to offer their congregations new exercise, wellness and cooking programs to encourage healthy lifestyles. The program, administered by the Camden Coalition, started with nine organizations in 2015 and now has 20 faith-based organizations involved, touching 350 lives last year.
“The technology part is the easier part,” Tillman noted. “Whereas, getting people to come to the table and getting their staff to go and change workflows, it’s a leap of faith.”
Tillman also said she would like to see more federal guidance on confidentiality rules around social services information. “The rules change a little and we’re trying to understand how the rules of confidentiality differ, since HIPAA [The Health Insurance Portability and Accountability Act] governs healthcare, what governs social services information? It’s a long conversation that we have with every partner.”
