Sharing health and social services in a region to support care coordination

In any given week, an individual may visit a primary care doctor, a food bank, a homeless shelter, and a behavioral health counselor. But if that person then goes to the emergency room, none of their care providers will be notified and their emergency room team won’t know that they’re connected with other agencies for care. This creates barriers to follow-up, community support, and informed treatment. 

Community information exchanges (CIEs) can address these challenges.

Here are five things you need to know about Community Information Exchanges:

1. A CIE is a network of partners in health and human services that share data, integrate technology, and coordinate services in order to provide whole person care to members of the community.

   Collaboration is the key to CIEs. Partners are working together to better serve their clients or patients. This is especially important for populations with increased health and social needs, such as people experiencing homelessness, older adults, and people who use multiple public assistance programs.

2. Informed consent from participating patients or clients is required.

   People who live in a county or region with a Community Information Exchange may be asked for consent to share data with local partner organizations in order to improve care coordination. If the person agrees, their data will be accessible by partners in the CIE and their providers from different organizations will be able to see the  services they receive.

3. The benefits of CIEs include better health and improved quality of life.

   With enhanced  care coordination, people may experience more personalized treatment and appropriate follow-up, and, therefore, improved health outcomes and  chronic condition management.

4. CIEs can address the social drivers of health–also referred to as social determinants of health (SDOH)–and advance health equity.

   CIEs facilitate collaboration between health and social services organizations, enabling a whole person approach to care. Participation in the CIE connects clients and patients to a network that can better support their holistic health needs. 

5. CIEs are already in place in cities and states across the country.

   The San Diego CIE has over 130 partners and more than 300,000 participating patients. These collaborating organizations use shared language, interoperable technology, and a resource database to provide coordinated care to individuals in San Diego. Sonoma County and Alameda County have implemented similar models. The states of Oregon, Washington, and Michigan are in the early stages of studying and testing a statewide CIE. CIEs are a promising model to address siloes in the health and social services systems while advancing equity and care coordination.