Unlocking the Potential of Community Information Exchange for Whole Person Care

By Karis Grounds, Vice President of Health and Community Impact, 2-1-1 San Diego
LinkedIn: Karis Grounds
LinkedIn: 2-1-1 San Diego

Timi Leslie, President, BluePath Health
LinkedIn: BluePath Health

When people are in crisis—whether it’s from a community disaster or a critical need for food, housing, and financial support—it’s hard for them to know where to turn, much less how to best navigate available resources. In these cases, hospitals, police departments, and public health leaders are often relied on for interventions, but they’re not always set up for ensuring long-term, holistic care for individuals and families.

That’s where community information exchanges (CIEs) come in.

The coordination of health, behavioral health, and social services in a patient centered manner, that is whole person care, results in improved health and wellbeing through the more efficient and effective use of resources. Fully accessible comprehensive data that goes beyond clinical information is necessary to provide appropriate coordination.

Unfortunately, many communities today are missing this critical data infrastructure, which is needed to blend community and social services with the health care delivery system to support transitions towards whole person care.

The Value of Community Information Exchanges

A CIE is a network of multidisciplinary partners that use a shared language, a resource database, and an integrated technology platform to deliver and coordinate community services. Available care planning tools enable partners to access information from multiple sources and make referrals, which feed into a shared longitudinal record of an individual’s health and social service history.

CIEs are often used in coordination with more commonly established and utilized health information exchanges (HIEs) to enable more comprehensive longitudinal patient records. Similar to CIEs, HIEs are responsible for facilitating the secure exchange of electronic information, but historically, have focused on sharing clinical data among health care providers to support the delivery of medical care.

Together, CIEs and HIEs can improve health and wellbeing by creating a seamless care experience that considers and supports the whole person.

CIE initiatives emerging across the nation can refer to key learnings and strategies from more established CIEs to jumpstart their programs, with insights available from 2-1-1 San Diego, one of the first and arguably most comprehensive CIEs.

Key Learnings for a Successful CIE

2-1-1 San Diego began its CIE in 2011 as a grassroots program initially designed to share basic client information between local providers to solve for homelessness in the community.

Realizing that care coordination is the key to solving many complex health and social problems, the CIE built and executed a broader vision to create a mechanism for care providers to better understand the full picture of health and social service utilization for all patients. Today, 2-1-1 San Diego operates a CIE that is inclusive of many different types of care providers across the county.

While each community has its own unique needs and existing data infrastructure, 2-1-1 San Diego has identified a few core elements that form the foundation of a successful CIE:

  • Close partnerships with community stakeholders to be responsive to community needs. For instance, 2-1-1 San Diego first worked with a small group of housing and homelessness service providers, but today their stakeholders and advisors include health care, social services, government, nonprofits, and community members with lived experiences.
  • Referrals and shared care plans, which are essential to community care planning.
  • Client consent for information sharing, which is critical to secure buy-in from CBOs to engage and exchange information.
  • Data and analytics for community-level insights.

While 2-1-1 San Diego is one successful example in action, a community should always consider their specific needs to develop CIEs for the most impactful approach. Some states are even building statewide CIEs with direct HIE involvement, such as Maryland by legislatively designating a health data utility, Rhode Island’s 211 Community Care Hub/HIE, and Michigan’s Department of Health and Human Services leading statewide efforts.

At the federal level, the White House recently published a playbook identifying CIEs, or community care hubs, as backbone organizations essential to a well-coordinated system of health and social care responsive to social determinants of health.

Support CIE Creation and Adoption

As health care systems continue to move towards whole person care, CIEs should be viewed as a critical component of health data exchange to ensure that care teams can address health, behavioral health, and social needs in a coordinated, comprehensive, and scalable way.

To support CIE development, in addition to the federal government’s educational and technical resources, more regulatory and legislative support alongside government, philanthropic, and health care system financial investments is needed. With more CIE initiatives involved to help drive connected, coordinated, and data-driven health care and social service delivery, whole person care initiatives will become more effective nationwide.