The integration of public health, social services organizations, and our health care system is vital to Connecting for Better Health’s mission to advance data sharing for all Californians. Connecting for Better Health welcomed members from the Common Health Coalition and 2-1-1/Community Information Exchange (CIE) San Diego to our coalition meeting on September 12, 2024 to present the important work their organizations are forging.
Unifying Public Health and the Health Care System
The COVID-19 public health emergency laid bare the need to enact preventive measures today to prepare for and prevent future public health emergencies. In 2023, three years after the onset of the pandemic, the Common Health Coalition was founded to strengthen the collaboration between health care systems and public health systems nationwide. During the pandemic, new partnerships between public health agencies and the health care system were created to strengthen the nation’s response to COVID-19. Continuing to leverage this momentum, including the focus on data sharing, and build upon these partnerships is central to the coalition’s mission.
Chelsea Cipriano, Managing Director of the coalition, joined C4BH to share the Common Health Coalition’s recent New England Journal of Medicine issue, which emphasizes the significant impact of public health on day-to-day care delivery. The coalition advocates for policy changes and fosters coordination between stakeholders to create a more integrated, actionable health system. The coalition highlights ground-level work being done at the intersection of health care and public health, strengthening an evidence base for the public health system. For example, the coalition has authored articles about the Pediatric Asthma Surveillance System to monitor the risk of pediatric asthma in communities and investigated the COVID-19 response partnerships that improved care delivery in an emergency.
At the federal level, the Centers for Disease Control and Prevention (CDC) launched their Data Modernization Initiative (DMI) at the end of 2019 to leverage public health data to target disease detection and eliminate existing or potential threats to population health. The DMI is the first of its kind to target modernizing public health data, technology, and workforce capabilities at a national level under funding from the U.S. government. Meaningful integration of public health and health care data at the local and federal level is critical to advancing data exchange that improves health outcomes. C4BH will continue to monitor progress by the Common Health Coalition and the CDC to spotlight findings and lessons learned in cross-sector data sharing.
Driving Community-Level Impact with a Minimum Data Set for Referrals
In addition to our discussion about public health data, Alana Kalinowski, Director of Interoperability & Collective Impact at 2-1-1/CIE San Diego joined us to discuss closed-loop referrals and the development of a minimum data set necessary for referrals. Kalinowski gave an overview of the organization’s mission to cultivate a network of health and social agencies that display an individual’s information in a longitudinal record which enables access to shared assessments, interoperability across systems, and closed-loop referrals that support whole-person care.
Kalinowski and the San Diego team have analyzed the minimum data elements that should be collected on every form that a patient or guarantor fills out to receive services from a health or social care organization. The effort emphasizes the importance of collecting data for monthly income and the contact information of a member, guardian or conservator to accurately determine eligibility for services. Currently, many organizations are not collecting this information, creating repetitive work for agencies to discover the information, create an analysis, and determine eligibility which can delay care and create unnecessary burdens for both individuals and providers.
Oftentimes the entity that initiated the referral on behalf of a client is not informed of the outcome of their referral– and thus, it is not a “closed loop.” 2-1-1/CIE San Diego is advocating for local partners to capture the outcome of the referrals and document what happened between the client and receiving party for the referral to be a true closed-loop and prevent confusion for care teams. Ultimately, the data capture should determine whether the client got the services they were referred to, and more importantly, the ability to understand the accuracy of the referral. For example, a closed-loop referral can inform the CIE of the capacity of their participating organizations and ability to respond to requests from partner agencies. Organization agreement on minimum data standards for referrals is a critical step in determining how and when clients can receive the most timely and appropriate care across health and social service organizations.
Robust data exchange across public health, social services, and the health care system is necessary to have a full picture of the health of communities, and identify populations in need of additional resources. If there is a disconnect between data gathering and medical or social organizations, providers are unable to create high-quality closed-loop referrals and direct individuals to necessary care. At the state level, California’s Department of Health Care Services recently released draft closed-loop referral guidance for the CalAIM program. Read C4BH’s public comment in response to the draft guidance here.
