The Early Childhood Results Count (ECRC) community planning effort, led by E3 Alliance and United Way, to create strategies to address school readiness among Central Texas students. Individual participants and partnering organizations made action commitments to carry these strategies forward through existing collaboratives and partnering organizations including Dell Medical School (DMS).
A key barrier to achieving the goals of the ECRC initiative is lack of data sharing across health, education, and human service providers. Community stakeholders are partnering with DMS to develop a data infrastructure (linking social determinants and clinical data) to facilitate Dell Medical Schools ECRC initiatives. The data infrastructure serve as the back-end data storage and management platform, and a community-based intermediary organization is responsible for data governance. An integral part of the system will be an intermediary interface application for managing consent and referrals.
For early childhood interventions in the community, Austin Independent School District (AISD) is ready to partner with DMS to share school district data for purposes as approved by a governance infrastructure. The governance body will comprise key community stakeholders and include AISD and DMS. The preferred way that AISD legal team has proposed sharing this data with DMS platform is for DMS to act as an “agent” for AISD to store and process the data. Early interventions based on this effort will not only benefit the children and families involved, but can also reduce or even eliminate the need to provide special services for children when they get older, thereby providing significant financial benefits for school districts.
Healthify is a healthcare company focused on addressing the social needs of individuals through technology and services.
Healthcare organizations can have multi-tiered needs around protected health information (PHI) at the organization, state, and even local levels. Healthify developed flexible client data privacy requirements to accommodate PHI policies. Healthify’s platform allows organizations to coordinate referral information to a network of partners and creates guardrails within the application to ensure that clients and their users are abiding by specific procedures. Although Healthify doesn’t determine policy for its clients, the framework of the technology enables them to determine what level of PHI to send, or share, with a social agency or community partner.
For example, a case manager at a health plan can screen an individual with HIV/AIDS for social needs and identify that they need supportive housing and a food intervention. The individual’s information entered into Healthify’s application is contextually dependent on what the healthcare organization has deemed necessary to share with each community partner. Because only basic information is needed to initiate a referral with a food bank, the details around HIV/AIDS are not included when the referral is sent and can’t be seen if the community partner views the member’s profile. These controls can be scaled down and up as appropriate based on each organization in the network.
NJII aims to reduce health disparities in the Newark community by targeting underserved areas with limited access to fragmented health care services.
The New Jersey Innovation Institute (NJII) created the Pop Up Health concept as a solution to building healthier communities. The concept was established and is operating in Newark, New Jersey, one of the state’s most urban areas with high percentages of racial/ethnic minorities, foreign-born, impoverished, and uninsured residents. These factors contribute to increased presence and severity of certain diseases, poorer health outcomes, and greater difficulty in accessing healthcare services.
The current goals of the NJII Pop Up Health Clinics include: addressing some of Newark’s most pertinent health needs (women’s health, health screenings, dental health, and HIV testing and education); increasing access to health care screenings and services; providing health education and, addressing social determinants of health by referring participants to local health and social service organizations; transitioning participants to a primary care provider; increasing Medicaid enrollment; reducing distrust and fear of the healthcare system; reducing fears of the undocumented and cultural issues with stigma; improving health literacy; improving health education on how to navigate the healthcare system to get the right service at the right place; and obtaining, addressing, and utilizing participants’ individual social determinants of health data to improve access to health care and overall health outcomes.
During NJII Pop Up Health Clinics, volunteer clinicians provide general consultations, health and disease-related screenings, and linkages to ongoing care. Services focus on the interests and needs of the participants and community, particularly performing blood pressure, BMI, and glucose screenings. Other health care services may include HIV screenings, vision screenings, dental screenings, tobacco use screenings/cessation interventions, depression screenings/follow-up plans, cholesterol screenings, health education, and health insurance enrollment. Clinics are held during other scheduled community events such as local food pantries and local health and wellness festivals.
The MiQlave app, developed specifically for use at NJII’s Pop Up Health Clinics, is the technology that drives services. This consumer-facing app built on blockchain technology is designed to provide participants access to their health data, and in time, connect this data with the records in the New Jersey Health Information Network (NJHIN). The app helps facilitate the Pop Up Health process/workflow. It also addresses a major healthcare data interoperability challenge by allowing participants to upload, maintain, and share their health information (e.g., BMI, glucose screening results, etc.) with any provider. The main objective of this highly-secure, breakthrough solution is to simplify the ability to share the participant’s health record so that a participant receiving care in the community (particularly through non-traditional care opportunities such as the NJII Pop Up Clinics) can easily store and share his/her health data with other health care providers. Unlike other personal health data sharing services, which include time-consuming and difficult processes for participants to create individual view permissions and to set the “share” criteria to each selected health care provider, the MiQlave app provides a unique solution for the participant to approve/deny the permission of the document(s) at the time of request through a secure messaging network. The participant does not have to set any preliminary permission rules.
At the Pop Up Health Clinics, participants can readily access their health data and assessment results through the MiQlave app. This information can be easily shared with other health care providers and multiple providers can subsequently load data into the MiQlave app. Eventually, NJII hopes to expand the scope of its Pop Up Health Clinic/MiQlave app project to establish an in-community clinic, manage care for community residents, educate providers on best practices, partner with providers for care coordination, and negotiate the use of treatment beds.
TAVHealth improves health outcomes and quality of care by solving Social Determinants of Health (SDOH). It does this by building accountable and curated networks of community and health partners that use the secure TAVConnect platform to safely collaborate and coordinate social services.
CHI St. Vincent Infirmary in Little Rock, Arkansas used TAVHealth’s cloud-based collaboration platform, TAVConnect, to address vulnerable patients who became reliant on the emergency department. Through their Health Connections Initiative (HCI) pilot program, TAVConnect was used to increase coordination, collaboration, and manage social determinants of health among participants.
TAVHealth identified the most vulnerable members through hot spotted zip codes and integrated the highest ED utilizers and their demographics in the TAVConnect platform. Collaboration among health and community partners increased coordination for these patients’ post-acute care. Social workers performed home visits to identify each patient’s social determinants of health and assigned the social risk to the most appropriate community resource. As a result of this initiative and partnership with TAVHealth, a 30 percent reduction was seen in 30-day hospital readmission rates, a 35 percent reduction in inpatient rehab admission, a 17 percent reduction in cost per patient admission, and a 10 percent reduction in the length of inpatient admissions. In addition, patients reported an increase in their confidence to manage their health, more meaningful relationships with their PCP, and reduced symptoms of depression.
Families living with autism in San Antonio, Texas have access to an abundance of community organizations providing a range of support services. Unfortunately, without a shared platform for collaboration, the amazing work of these organizations was undermined by limited coordination. This caused delayed response times for families, redundant data collection, and inconsistent outcome reporting by the agencies as required from their sponsors. To resolve these issues, the Kronkosky Charitable Foundation partnered with TAVHealth to launch Autism Lifeline Links (ALL), a collaborative program that increased coordination among community organizations to jointly manage social determinants of health and improve outcomes. Through its cloud-based collaboration platform, TAVHealth connected 10 autism support organizations, increasing collaboration by 10x to collectively identify and solve social determinants of health. Families seeking autism support could now enroll in ALL through a single point of entry. The platform provided structure, accountability and visibility across all 10 community organizations. They could operate as a unified virtual team, managing shared workflows, safely sharing information, and assigning the best resources to resolve members’ needs.
Real-time analytics allowed ALL to monitor and measure client volume, agency referral trends, and Pathway usage and could now identify and quickly remedy gaps in platform adoption and collaboration. By eliminating duplicative reporting efforts and maximizing agency resources, average response times dramatically improved from two weeks to 24 hours. A 9x increase in accountable referrals allowed community organizations to collectively solve 90 percent of all identified social determinants of health. Additionally, family enrollment burden decreased by 50 percent.