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 for low income and uninsured individuals, who often have limited and inconsistent access to care, which 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 December 2017, the CHF awarded an additional $100,000 to the two organizations to implement the second phase 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 involves:

  • Strengthening the consortium’s data sharing infrastructure to help measure the impact of connecting uninsured patients to a primary care medical home. Expected outcomes include:
    • Having updated HIPAA policies and protocols in place
    • Increased understanding of the CARES Program’s impact on emergency department utilization
    • 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
    • The development and dissemination of a CARES program year-2 impact report to key stakeholders
  • Collecting and analyzing data from La Clínica’s SDoH screening tool, called PRAPARE, which it is extending to all of its Contra Costa clinics. Specifically:
    • La Clínica and the Consortium will exchange PRAPARE data monthly on a subset of 500 patients, including at least 250 CARE enrollees.
    • Consortium staff will conduct data analysis and report 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 will develop an intranet resource guide that will enable its providers to connect patients to community resources as socio-economic needs are identified.
    • The Consortium will assemble 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.