Using social and medical data integration to improve primary care and population level chronic disease prevention and management

项目总结/摘要 随着有关社会和经济因素对健康影响的证据越来越多，医疗保健组织 越来越多地尝试更好地整合社会和医疗服务的战略， 健康成果。这些全人护理方法的一个关键要素是识别患者的社会风险 （c）促进向相关的内部或外部社会服务机构，例如粮食银行、住房和社会服务机构， 支持服务，福利援助，或医疗法律伙伴关系。促进多部门社会关怀 协调在圣地亚哥，加州，2-1-1圣地亚哥已经开发了社区信息交换 (CIE)这是一个多组织数据共享系统，旨在改善San Francisco的护理协调和结果。 迭戈最脆弱的居民在初级保健接触中，提供者可以访问CIE以查看有关 患者的社会危险因素和服务利用。CIE使提供者能够在护理点调整治疗 尽量减少社会风险对治疗成功的影响。CIE还提供了一个平台， 医疗服务提供者可将病人转介到与已查明的社会风险有关的非医疗服务机构。CIE吸引了 作为多部门护理协调的典范受到全国关注。然而，迄今为止， 研究了CIE的综合健康和社会数据分析如何影响临床护理、人口健康 管理或社区卫生干预。作为CDC拨款的一部分，2019年7月2-1-1圣地亚哥将开始 将CIE平台整合到三个联邦合格医疗中心的电子医疗系统中 （社区卫生服务中心），以促进健康和社会需求数据的无缝整合和慢性病的双向转诊。 疾病预防和管理。我们建议利用这一新的联邦资助倡议， CIE为相关的初级保健、人口健康管理和社区机构利益相关者提供服务， 评估增强的数据对慢性病初级保健和社区干预的影响。第一、 我们将使用以人为本的设计过程，以了解和优先考虑使用社交网络的障碍和促进因素， 慢性病相关患者护理、人口健康管理和社区健康的风险数据 规划我们将使用这些信息来完善所呈现的综合社会和医疗风险数据仪表板 相关利益攸关方。在部署这些仪表板之后，我们将使用混合方法设计， 评估其对慢性病相关患者护理、人口健康管理的多层次影响， 社区健康改善措施。我们还将确定患者、提供者和组织因素 影响仪表板在这些不同环境中的使用和影响。该项目将是第一个 评估这一最先进的社会和医疗数据集成工具对慢性病的影响 在临床和社区环境中的管理和预防活动，帮助告知类似的 美国各地的努力

Project Summary/Abstract As evidence about the impact of social and economic factors on health grows, health care organizations are increasingly experimenting with strategies to better integrate social and medical services in order to improve health outcomes. A key element of these whole person care approaches involves identifying patients’ social risk factors and enabling referrals to relevant internal or external social services, for example to food banks, housing support services, benefits assistance, or medical-legal partnerships. To facilitate multi-sector social care coordination in San Diego, California, 2-1-1 San Diego has developed the Community Information Exchange (CIE), a multi-organization data-sharing system designed to improve care coordination and outcomes for San Diego’s most vulnerable residents. In primary care encounters, providers can access the CIE to view data about patients’ social risk factors and service use. The CIE enables providers to adjust treatment at the point of care to minimize the impacts of social risks on treatment success. The CIE also provides a platform through which providers can refer patients to non-medical services relevant to identified social risks. The CIE has attracted national attention as a model for multi-sector care coordination. However, to date, no formal evaluation has examined how the CIE’s combined health and social data analytics affect clinical care, population health management, or community health interventions. As part of a CDC grant, in July 2019 2-1-1 San Diego will begin integrating the CIE platform into the electronic health systems of three Federally Qualified Health Centers (FQHCs) to facilitate seamless integration of health and social needs data and bi-directional referrals for chronic disease prevention and management. We propose to leverage this new federally-funded initiative to enhance the CIE for relevant primary care, population health management, and community agency stakeholders and to evaluate the impact of the enhanced data on chronic disease primary care and community interventions. First, we will use a human-centered design process to understand and prioritize barriers and facilitators to using social risk data for chronic disease-related patient care, population health management, and community health planning. We will use that information to refine the integrated social and medical risk data dashboards presented to relevant stakeholders. Following deployment of these dashboards, we will use a mixed-methods design to evaluate their multi-level impacts on chronic disease-related patient care, population health management, and community health improvement interventions. We will also identify patient, provider, and organizational factors that influence the use and impact of the dashboards in these different contexts. This project will be the first to evaluate the impact of this state-of-the-art social and medical data integration tool on chronic disease management and prevention activities both within clinical and community settings, helping to inform similar efforts across the U.S.