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Many of the strongest predictors of health and well-being extend beyond hospital walls and into our neighborhoods, schools, work places and homes. Tackling the root causes of health disparities often requires that communities engage and partner across multiple sectors. For many, a critical first step is to share data that generates a more complete picture of individual and community health. Through the integration of health data and evidence from sectors like housing and education, local residents and leaders have the ability to better detect problems, test interventions, and ultimately transform environments to improve health.
All In: Data for Community Health is a national network dedicated to building the capacity of local collaborations to capture, integrate and use data to address social determinants of health. The two founders of All In—Data Across Sectors for Health (DASH) and the Community Health Peer Learning Program (CHP)—collectively represent a cohort of 25 community projects. Through this expanding community of practice, they are engaged in peer-learning to support exchange of lessons learned and promising practices that can accelerate local and national progress. This blog illustrates how DASH and CHP projects are sharing data across sectors—specifically housing, education, social services, and criminal justice—to create healthier environments where people live, learn, work, and play.
Through the integration of health data and evidence from sectors like housing and education, local residents and leaders have the ability to better detect problems, test interventions, and ultimately transform environments to improve health.
Examples from the Field
Recognizing that safe and affordable housing is a key component of health, Public Health Seattle & King County is partnering with local public housing authorities to create an integrated data system that links administrative housing data to Medicaid claims records—creating a de-identified data set that will be shared back with the housing authorities. This project, part of the King County Accountable Community of Health, is the first time health and housing partners are working to securely link data between sectors to inform new interventions to improve health and quality of life for subsidized housing residents. As health concerns are revealed by the data sharing, public health and the housing sectors can align efforts to address specific health needs of the residents. For example, they may work to reduce exposure to asthma triggers in the home or offer diabetes prevention classes in public housing facilities.
Working to help Cincinnati’s kids to be the healthiest in the nation through strong community partnerships, the Cincinnati Children’s Hospital Medical Center (CCHMC) is integrating electronic health records, school data, and geographic information systems data to identify where and when children in the Avondale neighborhood are at disproportionate risk for asthma events. Working with integrated data, CCHMC aims to address underlying social determinants (e.g., safe housing) and reduce inpatient hospitalizations for pediatric patients. Their data sharing approach involves three phases: 1) convening a work group to define measures of interest 2) defining processes for using those data to improve community health; and 3) using the developed infrastructure to inform and evaluate small-scale tests of change.
The Baltimore City Health Department and its collaborators are leading a city-wide effort to reduce falls among older residents by sharing timely, comprehensive data with a diverse set of stakeholders. By creating a real-time data surveillance system to track fall-related emergency department visits and hospitalizations through Maryland’s Health Information Exchange, they’ll be able to identify hotspots for falls across the city. As outlined in a recently adopted health department regulation, B’FRIEND will identify the geographic distribution of falls and other risk factors and individuals that have suffered from a serious fall or are at high risk. Community partners from housing, social services, aging, and others are eager to use the data in a number of ways, such as implementing evidence-based exercise interventions, making improvements to the built environment, or offering targeted facility repairs.
Health information technology can be effectively used to support shared management and coordinate care. The CHP Program’s Crescent City project is leveraging its Health Information Exchange and working to integrate clinical, public health, and private/public records data to identify and intervene for severe and persistently mentally ill and vulnerable populations that are high utilizers of emergency departments, the criminal justice department, and social services agencies. Through their collection of electronic health records and other health data, the project aims to improve health outcomes and reduce costs of care. Their strategy includes convening stakeholders, conducting a requirements analysis, developing a solutions architecture and data definitions, and devising appropriate data governance structures. Ultimately, the Crescent City project would like to improve the effectiveness and efficiency of care coordination, and support better access to services for approximately 400 people suffering from behavioral and mental health conditions.
Looking for more information on current efforts to improve community health through multi-sector data sharing? Read the second post in this series, which highlights key insights gleaned from these projects that can help communities in the early stages of multi-sector data sharing and collaboration.