This project will enhance and evaluate the impacts of dashboards sharing integrated social and medical risk data to improve coordination between clinical and community settings.
What is the research about?
San Diego’s Community Information Exchange (CIE) is a data-sharing system that allows health clinics and social service organizations to share information about patients’ social risk factors and use of social services with the goal of improving care coordination for vulnerable patients. The CIE allows primary care clinicians to refer patients to needed social services (such as food banks, housing support services, benefits assistance, or medical-legal partnerships) and take relevant social risk factor information into consideration at the point of care when developing treatment plans.
A Centers for Disease Control and Prevention (CDC) grant is supporting the integration of the CIE platform into the electronic health systems of three federally qualified health centers (FQHCs) to facilitate referrals between the clinics and social service agencies. This AHRQ grant builds on that effort by enhancing the CIE tool and evaluating its impact on effectiveness of the CIE for cross sector care coordination in both clinical and community settings. The research team is first identifying key barriers and facilitators among stakeholders to using social risk data, and then using that information to refine the CIE dashboards. The research team is then conducting a mixed-method evaluation to examine the adoption and impacts of these improved CIE dashboards.
Results from this study are forthcoming. Future publications from this grant will be posted here.
Primary Care Relevance
The CIE is a national model for innovative multi-sector care coordination. Findings from this evaluation will help inform similar efforts across the country to integrate social and medical services in primary care to improve health outcomes for vulnerable patients.
AHRQ Primary Care Priority Area
Harnessing data and technology to conduct research on characteristics of primary care that may influence patient outcomes, such as whole person care, care coordination, continuity of care, and comprehensiveness of care.
