Interoperability in the Age of Value-Based Care


The Health Collaborative and Healthify discuss the role of interoperability on SDoH care coordination

THC Webinar

As healthcare organizations develop social determinants of health (SDoH) strategies to address social needs, integrating community-based organizations (CBOs) into the clinical ecosystem has become a critical step in value-based care. Unfortunately, siloed technology and a lack of interoperability are still significant obstacles in these partnerships. 

In our latest webinar, we join The Health Collaborative to discuss the role of interoperability in value-based care, and how it's reshaping SDoH care coordination between clinical and nonclinical organizations in Greater Cincinnati. 

How The Health Collaborative is working with its community

The Health Collaborative is a Cincinnati, Ohio-based multi-stakeholder convening organization, delivering cross-sector solutions and health improvement pilot projects to the region. Created by The Health Collaborative, Gen-H Connect is a CMS Innovation Center-sponsored initiative that evaluates whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries impacts total healthcare costs and utilization rates.

Gen-H Connect reviews transportation, utilities, interpersonal violence, and food domains in the community and resultant emergency department use. The Health Collaborative and Gen-H Connect partnered with Healthify to create the Cincinnati Community Network, and through the network, partners implement four critical components:

  • Universal screening to identify specific unmet health-related social needs
  • Referrals to increase awareness of community services
  • Navigation services to assist high-risk with accessing community services
  • Encouraging alignment between clinical and community services to ensure services are available and responsive 

Financial incentives for CBO participation

On the webinar, Manik Bhat, Founder and Chief Executive Officer at Healthify, noted that infrastructure is critical to help show value and revenue for CBO partners. CBO incentives will be paramount for the success of future SDoH engagements.

“Ultimately, we feel we need to head for a way to pay for community services at scale,” Bhat said. “The bedrock of allowing network coordination to happen means we have to get the incentives for community partners right. They are excited but also want to know what’s in it for them to share information.”

Connecting disparate systems in a SDoH network

Alex Vaillancourt, Chief Information Officer and Senior Vice President of Informatics at The Health Collaborative, noted on the webinar that health data enables richer insights and can create a single, longitudinal record across a SDoH community network. However, there are challenges along the journey.

Vaillancourt identified three significant challenges:

  • Data Standards: From HL7 and C-CDA to APIs, data standards currently have enough flexibility to make integrations an exhausting process.
  • Identity Management: Managing different records, name nuances, etc. can be an issue in a community. Towns with large families and poor data from independent labs can all throw a wrench into synthesized identity programs within healthcare data.
  • Privacy and Security: HIPAA challenges data-sharing and can cause distrust of data in some cases.

Leveraging integrated data to identify social needs

Ben Dawson, Data and Informatics Analyst at The Health Collaborative, shared that when health data sources are integrated, organizations can identify and determine SDoH interventions in their community.

For example, through the Cincinnati Community Network, The Health Collaborative found that self-reported food insecurity was the most significant social need in the community (32 percent self-reported this need). Dawson also noted that health-related social needs are not evenly distributed throughout geographies. Food insecurity increased 12 percentage points to 44 percent when isolating the same social need in just black, urban communities.

He noted that monthly dashboards help The Health Collaborative decide resource allocation. Their next step is to compare national food desert data with its regional data to review any correlations to national trends.

Beginning interoperability efforts for SDoH

Before taking questions from the audience, Vaillancourt offered some helpful tips and thoughts to consider before an organization begins a data integration effort to create a community network:

  • Get to know and understand your data
  • Apply that data to solving a healthcare challenge
  • Be thoughtful about additional data you might need to boost the goals of your network
  • Determine what community partnerships make sense to further your mission

Lastly, he shared that organizations should share their stories so that other organizations can learn from each other as they move to integrate data.

Watch the webinar to learn more about the role of interoperability in value-based care and how it's reshaping SDoH care coordination between clinical and nonclinical organizations in Greater Cincinnati. 

Watch now

Topics: webinar care coordination sdoh technology SDoH data

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