When health care providers cannot efficiently share health information – when they do not have a complete health history or understanding of the whole patient, including the social determinants of each individual’s health – care suffers. This is a particularly acute concern in caring for low income and uninsured individuals, who often have limited and inconsistent access to care, which in turn, causes information gaps that compromise clinical decisions, as well as planning and policy efforts aimed at more efficiently delivering care.
In December 2016, concerns about such gaps resulted in the Community Health Fund (CHF) awarding the Contra Costa & Solano Community Clinic Consortium and La Clínica de La Raza a $123,000 grant to enhance data sharing capacity among local community health centers and hospitals who are part of Contra Costa CARES – a partnership between community health centers and hospitals to meet the needs of uninsured and undocumented individuals.
In each of the ensuing two years, the CHF awarded an additional $100,000 to the two organizations to help implement the second and third phases of their collaborative three-year plan.
During Phase One, the two groups:
- Adopted and implemented a HIPAA compliant collaborative electronic file sharing platform
- Developed and implemented data sharing policies and protocols, trainings, workflows and ongoing technical assistance for CARES partners
- Created a financial incentive program for CARES partners to supply timely data via the new data infrastructure
- Developed an infrastructure at La Clínica’s Monument clinic, which includes a screening tool for the social determinants of health (SDoH)
Phase Two involved:
- Strengthening The Consortium’s data sharing infrastructure to help measure the impact of connecting uninsured patients to a primary care medical home, with outcomes that include:
- Updated HIPAA policies and protocols
- A data sharing relationship with Walgreen’s and the piloting of a program for sharing pharmacy data on a subset of CARES program enrollees, to begin to understand the program’s impact on medication use
- Development and dissemination of a CARES program year-2 impact report to key stakeholders
- Collecting and analyzing data from the SDoH screening tool, called PRAPARE – and extending the tool to all of La Clínica’s Contra Costa clinics. Specifically:
- A monthly exchange of PRAPARE data, between La Clínica and the Consortium, on a subset of 500 patients, including at least 250 CARE enrollees.
- Consortium staff conducted data analysis and reported back to La Clínica with recommendations aimed at helping identify needed outside support services and informing intervention strategies and partnerships that will address patient needs and clinical needs for achieving and maintaining good health.
- La Clínica developed an intranet resource guide that will enable its providers to connect patients to community resources as socio-economic needs are identified.
- The Consortium assembled a local workgroup to disseminate the La Clínica SDoH findings and begin to facilitate the development of partnerships between clinical and non-clinical service providers.
Phase Three involves:
- Continued expansion and refinement of the data sharing infrastructure to determine the impact of connecting uninsured patients to a primary care medical home, and better understand the needs of the remaining uninsured in Contra Costa County. This will involve development and dissemination of a CARES program year-3 impact report that will contain new data on items ranging from the participants’ health status, medication adherence and satisfaction with care through remaining gaps and barriers to care and important measurable trends.
- Continued collaboration aimed at developing and enhancing the collection and analysis of SDoH data among patients and using the findings to spur appropriate action. Key expected outcomes include:
- The ongoing, monthly exchange of PRAPARE data to capture and analyze key information about a new subset of 500 patients, including at least 250 CARES enrollees
- La Clínica developing a mechanism to document staff actions and outcomes aimed at addressing SDoH needs the organization can now identify
- The Consortium creating a quarterly dashboard of PRAPARE trends and completing an annual analysis to help inform La Clínica’s program planning
- Convening of a Contra Costa SDoH Learning Collaborative consisting of local clinical and non-clinical service providers, in which workgroups will identify gaps, opportunities for collaboration and methods to address unmet needs
- Development of materials to highlight findings and recommendations from SDoH data analysis to share with local, regional, statewide and national stakeholders seeking to address SDoH through policy and systems planning