From Los Angeles to San Diego, closed-loop referral systems and cross-agency collaborations are setting new standards in care coordination, using data as the key driver. On September 26th, Los Angeles Network for Enhanced Services (LANES) joined Connecting for Better Health alongside a partnership presentation between 2-1-1/Community Information Exchange (CIE) San Diego and Regional Taskforce on Homelessness to give coalition members an overview of their recent projects that utilize data to address local health and social issues.  

Expanding Access to WIC Agencies Through LANES

To discuss a recent pilot program in Los Angeles designed to connect Women, Infant, and Children (WIC) Agencies with health care providers in Los Angeles, Ali Modaressi, CEO of LANES, gave insight into the closed-loop referral pilot conducted from January-August 2024. LANES is a Qualified Health Information Organization (QHIO) that serves as an intermediary for data exchange between health and social care, reducing the burden on providers and patients to manually send information from one source to another. The project aimed to streamline care coordination between local WIC agencies and Federally Qualified Health Centers (FQHCs), using LANES. By integrating WIC Management Information Systems (MIS) with the LANES platform, health care providers from FQHCs are able to generate patient rosters from well-child and prenatal visits. These rosters are sent to WIC staff, who can then access health data through the LANES portal. This approach enabled WIC nutritionists to make better-informed decisions and reduced the time spent gathering health records. The integration of data at the two clinics created over 9,500 referrals through LANES, aiding WIC staff access to critical, timely health data and improving care coordination. 

Today, the pilot is being used in everyday workflows among early adopters, and there are additional proposals to implement the pilot in other WIC agencies across the state. 40% of infants in California are born into Medi-Cal, California’s Medicaid Program, underscoring the need for public programs to serve as a backbone for new mothers and their children by providing nutrition education and support. The sharing of data between WIC agencies and providers is vital to ensure individuals eligible for WIC are receiving the right services.

A Collaborative Approach to Combat Homelessness Using Data

The partnership between the Regional Taskforce on Homelessness (RTFH) and 2-1-1/CIE San Diego highlights a multifaceted approach to address homelessness in San Diego County, estimated to have a population of over 10,000 unhoused individuals as of January 2024. Tamera Kohler, CEO of RTFH and Camey Christenson, Chief Business Officer at 2-1-1/CIE San Diego, joined C4BH to discuss the integration of Homeless Management Information System (HMIS) data into San Diego’s CIE allowing for a single-point of consent and data integration, and a streamlined process to track client data, program enrollment, and outcomes. By creating a single-point joint consent, clients are able to opt-in to both the HMIS system and CIE giving both organizations insights to the needs of unhoused individuals, the need for California Advancing and Innovating Medi-Cal (CalAIM) services, and the ability to provide assistance with Managed Care Plan enrollment.

2-1-1/CIE San Diego participated in the Homeless Emergency Aid Program (HEAP), a state funding program that provided assistance to California’s homeless Continuums of Care (CoCs) and large cities to tackle the homelessness crisis. The CIE was used by 11 homeless organizations as the intermediary to help screen and document outcomes for unhoused individuals. By evaluating the data, San Diego CIE was able to deduce that individuals eligible for HEAP were 7x less likely to experience homelessness, and monetarily the data illustrated that preventing homelessness through programs like HEAP cost 24% less than providing homeless services. 

The progress made by the two organizations is rooted in the strong partnerships and trust built within the community, with an emphasis on data integrity, sharing, and adapting to changing requirements. This collaborative effort has enhanced the region’s capacity to address homelessness at both individual and systemic levels. 

Do you have a local data sharing collaboration to share? C4BH is always interested in spotlighting projects like these two in San Diego and Los Angeles. Reach out to info@connectingforbetterhealth.com with your community use case to share.