IMB1 - Leveraging Social Determinants of Health Data to Improve Care Services and Public Health Surveillance

Session Description: Unmet social needs are a known contributor to poor health outcomes. Advancing technology provides new opportunities both to incorporate contextual information regarding social determinants of health (SDOH) and to link primary care providers with social service providers able to address some of these broader needs. AllianceChicago, a Health Center-Controlled Network, has worked on 2 public health projects that illustrate how we can exploit emerging data standards and new approaches to access data from disparate data sources to improve the way social needs are identified and addressed among healthcare, public health, and social service agencies.

The cardiovascular disease and SDOH (CVD-SDOH) project, funded by NACHC and CDC, extends the current data infrastructure to enrich CHC EHR data by adding in contextual data coming from a broad range of relevant sources of SDOH data, to provide a more wholistic view both to the CHC providers as well as for public health surveillance.

The Aligning Health and Housing project, funded by the Office of the National Coordinator, leverages an open-source application (eCare Plan Hub), which receives service referrals through the CHC Electronic Health Record (EHR) using FHIR (Fast Healthcare Interoperability Resources). The eCare Plan Hub integrates screening tools and better coordination and care planning among CHCs and community-based organizations (CBOs) that support the unhoused.

These projects utilize technology to address and document SDOH for prevention and access to resources.