ITuB3 - CANCELLED: Facilitating Community Data Sharing to Support Social Needs

Session Description: Paso del Norte Health Information Exchange (PHIX) is partnering with health care and community organizations to extend data sharing beyond clinical data to include social determinates of health. These partnerships enable PHIX to identify patients with social needs and allows PHIX to help facilitate referrals to supporting agencies. For example, El Pasoans Fighting Hunger Food Bank has partnered with PHIX so that providers can send closed-loop electronic referrals for patients experiencing food insecurity, who have chronic conditions, to their Food FARMacy. PHIX can also help auto generate these referrals through the use of health care center pre-identified flags like ICD-10 code Z59.41(food insecurity) or particular responses to social screening tools. Once received the Food FARMacy coordinates care with patients and provides disease specific nutrition education and free groceries weekly for a period of time. This level of care coordination, education, and intervention is an effective and innovative way to support patients with management of their chronic diseases while meeting some social needs. Moreover, PHIX aims to work with partners to assess the long-term health impact of referrals to social services agencies such as the Food FARMacy to assess intervention value, current health care needs, and future strategy for community collaborations/interventions. Our goal is to promote community data sharing and support the holistic needs of patients for improved community health outcomes.