Sonoma Connect/Sonoma Unidos, a coalition tackling childhood trauma, offers an example of a people-centered network of care that is built upon information sharing and community engagement across sectors. The coalition of community leaders and partner organizations in Sonoma County is working together to eliminate adverse childhood experiences caused by social determinants of health (SDOH) and racism.
Beth Paul, population health director at Aliados Health (formerly Redwood Community Health Coalition), spoke about Sonoma Connect at the December 1 Connecting for Better Health meeting. Her organization supports community health centers throughout a six-county area in Northern California and is one of Sonoma Connect’s key partners.
Sonoma Connect will support and coordinate community resources and connects them to people who need them. The organizations participating in Sonoma Connect have tripled in number since early 2021 to more than 91. Those include five school organizations, 44 CBOs, 14 health centers, six local and state government organizations, and 22 other organizations or individual community members.
Sonoma Connect’s community information exchange (CIE)-inspired network will deliver a robust resource database, care coordination, referral support, and a closed-loop referral technology system. What was missing? A technology platform to support this work.
“We really knew that it needed to be a system that was driven and led by the community, not something that was imposed upon the community,” Paul said.
In discussing challenges and opportunities, Paul pointed out the heavy lift of data governance, stressing that communities need support and expertise to ensure the successful implementation of California’s Data Exchange Framework (DxF).
The coalition is launching its initial implementation with a pilot cohort and will expand implementation to more partners in 2023. Paul said the organizations involved in pilots will start using the system for resources and referrals, and will pursue interoperability efforts in 2023.
The coalition, which has grant funding secured through 2024, is working to develop long-term, sustainable funding, and is looking at the potential to use the system to support CBO engagement in CalAIM.
Sonoma Connect is addressing problems that are common in many communities. Resources can be hard to find and aren’t interconnected. “This means people experience having to tell their story multiple times and may not receive services that are coordinated and aligned with their needs,” according to Sonoma Connect.
That is why “an HIE[health information exchange]/CIE is not just a technology platform,” Paul said. But rather, as Sonoma Connect exemplifies, HIE and CIEs are serving people and communities.