ONC Social Determinants of Health (SDOH) Information Exchange Learning Forum

great thank you everyone for joining I will hand it over to onc to get us started please thank you so much Chrissy all right everybody let's get started so thank you so much for joining the office of the national coordinator for health and information Technologies social determinants of health information exchange learning Forum my name isolase and I am a public health advisor with OMC we are very excited to be hosting additional webinars under the onc sqh information exchange learning forum and we really look forward to engaging with you all over the next couple of months today's webinar will be focused on the governance models that engage Community Partners so the social determinants of health seoh information exchange learning form is intended to bring together Health Care Providers community-based organizations government payers health information exchange networks I.T platform developers innovators and other partners to share Lessons Learned challenges and promising practices related to exchanging seoh data so for our agenda today on today's call since some attendees may be joining us for the first time we will provide a brief background on seoh information exchange including work that onc has been supporting we'll then do a recap of the framework of interrelated foundational elements that enable seoh information exchange with a focus on governance and hear from two of our spotlights UT Austin and the Michigan Health Information Network of my hand on their experiences we will then close out today's webinar with more information on the learning Forum webinar series and how to sign up for a small group discussion so a couple of quick reminders and notes this session is being recorded So if you do not consent to this recording you may disconnect now we will hold your questions until the end of presentation but we encourage participants to please chat in questions and comments at any time also note we have muted participants for today's webinar so please use the chat function for questions and comments the slides and recording for today's session will be available soon on onc's website on the event page for this learning forum and we'll put a link for that page in the chat we could go to the next slide so I am joined today by several other OMC colleagues including Mark knee and Samantha meckler in addition today's call has been supported by the Emi advisors team and subcontractors including including Chrissy solentano Evelyn Gallego Sarah bahal and Jillian annunciata these if you could put your name in the chat and organization so we'll know who we have on the call today go to the next slide and now I will hand over to Sam meckler from OMC to provide more background and information on sdoh transformation exchange and related Federal activities thank you so much to our returning friends and new friends we're grateful for your time and that you're with us today as we explore governance efforts to advance cross-sector social determinant of Health Data exchange a community partner engagement for the next few slides I'll offer a brief recap on the sdoh information exchange learning Forum the Department of Health and Human Services initiatives onc initiatives and publication of the swh toolkit let's go to the next slide so this slide is familiar to all of you no doubt and in large part it's why you're with us today because you recognize how unmet social needs can negatively impact Health outcomes and that addressing these needs is critical for achieving Health Equity Healthcare is only part of what goes into Health next slide so HHS is healthy people 2030 sets data-driven National objectives to improve health and well-being over the next decade and importantly healthy people 2030 has an increase in overarching focus on sdoh it includes many objectives related to sdoh that highlight the importance of Upstream factors usually unrelated Healthcare delivery and improving health and reducing Health disparities next slide so seoh objectives can also be found in the federal health I.T strategic plan as well the 2020 to 2025 federal health I.T strategic plan was developed across federal agencies with public input and it outlines objectives to integrate Health and Human Services as part of promoting health and wellness and outlines specific strategies centered on as examples advancing standardization and interoperability of sdoh and Social Service data and capturing and integrating sqh data into ehrs and decision support and also strategies around strengthening Community Health I.T infrastructure

next slide so the department has also released a strategic approach and plan to address sdoh to Advance Health Equity the three goals of this focus on building a robust and interconnected data infrastructure improving access affordability and Partnerships for health care and Human Services and community-based organizations and taking a whole of government approach the action plan includes an sdoh Health ecosystem visual that you see on the slide here this is really a framework with overlies tied to the plan across the entire stream Upstream Midstream Downstream and when you look across that you see enhanced data infrastructure standards and interoperability enable the data or here you could say the water to flow let's go to the next slide I want to take a moment to talk to you about the onc framework so this is how we really focus on four key areas with respect to how health I.T can be used to help achieve social determinant of Health interoperability and to Advance Health Equity it includes standards and data infrastructure policy and implementation as examples this entails guiding the development dissemination and Adoption of Health standards informing policy development to overcome social determinant of Health interoperability challenges supporting state and local government in partnership with our federal friends as they build infrastructure for Soh data and driving innovation in effective implementation workflows next slide last but not least we're so excited to share that the social determinant of health information exchange toolkit of rolled out just days ago this is article on the ground resource it was informed by a panel of experts as well as by you we included input from past learning Forum sessions as we shape this toolkit it can serve as a resource for initiatives that support the collection and use of Suh information in communities across the United States and includes considerations related to community engagement Health I.T standards infrastructure interoperability and governance it's structured around 10 foundational elements of s uh information exchange one of which is governance and that's what we'll focus on today so with that I'd like to turn it back to Chrissy and thank you all again so much for joining us this afternoon yeah great thank you so much Dan so go to the next slide so building on the information Sam just shared about the onc sduh information exchange toolkit I'm going to talk a little bit further about the foundational almonds framework so the framework consists of interrelated foundational elements developed to inform and Advance s2h information exchange initiatives and these elements include governance user support and Learning Network technical infrastructure data standards implementation services policy legal Finance measurement evaluation Mission and purpose value and principles and finally Community Readiness and stewardship and on the screen you can see the graphic representation of this framework for this framework different stakeholders and different types of stakeholders will prioritize and sequence their focus on the foundational elements as most appropriate it's not designed to be a one-size-fits-all approach but rather a conceptual framework that can guide the planning design implementation and evaluation processes of sdoh information exchange initiatives and this is really intended to help underpin the implementation of these initiatives and which could ultimately affect the initiative's capacity to build interoperable infrastructure components and services such as referral management resource directories identity management consent management Etc so on today's webinar we're taking a deeper dive into governance so on the next slide in the Highlight what the how the oncsdh information exchange toolkit describes governance which is really the decision-making processes in groups as it relates to institutional administrative and data governance governance happens at many different levels different scales including across communities across Community networks within initiatives that could represent Community within a community across the region and even at a state level an Institutional governance when we're talking about that what we're really talking about is terms of participation processes for leadership setting those priorities and then organizing and coordinating activities around those priorities administrative governance is really focusing in more on the policies guidelines agreements etc for establishing implementing monitoring and enforcing those activities and finally the data governance really sets the rules and guidelines around data stewardship technical standards and the information technology architectural design and how those different Pieces come together and we really want to highlight the significant role of community organizations in these types of initiatives from studying community-wide priorities within a given Community as well as the emergence of Community Care hubs community-based organization lead entities acting as trusted entities that are managing networks and services and engaging with other domains in cross-sector exchange initiatives so really helping to bring together a lot of different Community Partners to engage in these initiatives and in those initiatives governance activities go to the next slide So within the toolkit there are a lot of additional resources and information on governance including guiding questions examples of bright spots you know promising approaches challenges just really working through different components of the landscape to share with interested stakeholders um so we won't cover all of that information but definitely check out the um the toolkit to get a deeper dive but before we go further we just want to share a couple of examples of the types of guiding questions that you and your partners participating in your initiative could be asking to help explore your governance structure and what will make the most sense for you so just a couple as an example for institutional governance questions to be asking could be around how will terms of membership and participation be handled and who will determine those guidelines and rules regarding administrative governance how will policies pertaining to information sharing incentives and evaluation being made and changed and who will be responsible for policy making implementation enforcement and finally how will accountability be handled for data governance some of the questions to be thinking about include what data standards and Technical Systems design will be selected and adopted how will those standards be implemented and monitored to ensure alignment and in addition considerations around how to design vendor agnostic approaches to exchange and how an initiative can enable that with that I will hand it over to Malay to introduce our first speaker and thank you Chrissy um so now I'd like to introduce the myhim team including Lisa Nicolo the cross sector data sharing program director and Mike klinkmann the class sector data sharing medical director video joined by Don Opel from the Food Bank Council of Michigan this team will speak on governance efforts and to advance cross sector data exchange and engage with Community Partners all hands off over to my hand thank you hi there I'll uh I'll go first um so uh thank you for inviting us again on this uh exploration and coming together um we're here to represent Michigan health and Information Network in and the Michigan path to kind of data sharing across social sector and health sector and the role that the governance has played both now and as as we lead into the future um next slide so um again Lisa Nicola I'm the cross-sector data sharing program director I don't want to get into kind of anything about myself the reason uh however we are called the social the cross-sector data sharing uh program versus the um the social determinants of Health uh uh program is that we really wanted to be very explicit about what it is that we are doing within this space and how what our contribution to the work going forward is um I have two colleagues with me today uh both fabulous and incredibly much more knowledgeable than I am Don do you want to take a moment sure my name is Dawn opal I'm with the food bank Council of Michigan uh we represent all of the feeding America Affiliated food banks and pantries in the state of Michigan who are doing a myriad of uh sdoh related uh data sharing initiatives around the state and my office and my research team Pilots uh several of those and we'll be talking to you today about our partnership with my hin Dr k Mike winkmann I am a practicing family doc kind of first and foremost in most of my life and have been working in this space to try to make sure that as a primary care doc we can do a good job of taking care of our patients when their needs go beyond strictly medical so I've been doing this for a long time many failures behind me that we can talk about at leisure someday but um like Lisa said we're a great team at my hand trying to do a lot of very hard work Becky Lisa all right next slide so for those of you who are not familiar with who am I in his we are the Michigan Health Information Network we are the state designated hie um we are a growing uh organization and network of organizations trying to uh to share data across the state we include Regional hies we are working to do all of those good things that my that that sharing of data it promises to to manage and we are working collaboratively with other organizations within the state to be able to overcome some of those data sharing barriers next slide I think everybody's seen some variation of this in the past but kind of we don't treat patients we don't treat individuals in silos we treat individuals in many many different spaces so prior to health information exchange certainly there's a lack of coordination duplication evaporate lots of waste lots of expense and ultimately lots of cost um uh the goal of my hand is really to connect once and share across all of those different organizations and now that is extending to our social care provider teams as well um and within our space we're also looking at things like school systems criminal justice systems so taking that Beyond just Health and Social care but expanding that into all of the organizations that have a a designated interest and and role to play in resolving social need side really busy slide here but the point of this is um in that decades-long plus Journey or decade uh plus a journey uh from inception of my hand to to to to now there's been a lot of support a lot of work that has gone into getting to the state where the healthcare data is being shared that includes um federal and state level support through grants through uh incentives through um the standards through um the legal and policy changes and all of that work has really kind of culminated to where we are now most importantly in terms of data sharing governance and and and the the role that we have to be able to bring social care in that journey is much shorter so we're still in the infancy of that and um there hasn't been to date as much support to be able to bring that social care um space along in that Journey so there's still lots of work to be able to do in there next slide um there is um uh our strategy and I don't want to go too heavily into this because the the meat and the potatoes of our 15 minutes should really be spent on Lessons Learned our strategy to build um capacity for social care data is very very simple we really want to work with what's already in the community we have great examples through um uh Regional and state level demonstrations that have gone on in the past through the state Innovation model or the Michigan Primary Care transformation demonstration to be able to really build on that not just with the eye of solving kind of one-to-one needs but moving that data Upstream to really uh impact Health Equity uh so wanting to always work with what is already within the community versus build on top of um uh or replace build on a common cross-sector care model this is something that I think we maybe in the past uh not we but at the the global we we have overlooked that idea of a common care model that drives that common data models can get glossed over so we're really kind of trying to resurface that and socialize that and make sure that we understand the roles that that plays in terms of driving data and work within our own existing toolbox my hand is a well-established health information exchange with lots of good legal technical convening capacity and and our ability to drive through our use case Factory so making sure that those exact same tools can be utilized within the social care space and then obviously employing gravity standards wherever possible next slide um our team while we have uh not just been in existence since um August of 2021 there's been lots of movement within my head and lots of people kind of dedicating effort towards it but that formalization really represents the focus that Mayan is placing and the emphasis that my hand is placing on making sure that we can participate actively and really kind of move Michigan forward uh to share data for social care purposes again supporting that cross-sector use cases supporting our subject matter expertise and continuing our role in acting as a neutral container next slide activities that we're involved in again lots that have have gone on in the past uh between our accountable Healthy Communities effort and state Innovation model demonstrations that formed what are now uh Community uh Health Innovation regions but are really great examples of regional cies with varying governance models but being able to work with them as they continue their evolution we want to work with our community of practice our vendor our social care referral vendor community of practice that was formed in August of this year underneath the the interoperability pledge and I think the the take-home messages that interoperability pledge is really just a piece of paper the heart of the and the magic of it is really that these vendors who are commercial competitors have really come together around the exact same table to um to to Really uh resolve the issue of multiple vendors operating in a single space that create those silos so really trying to move that forward more to come on that uh we want to use those vendors as the platform and the tools that they can be to help Supply Necessary Technology within community that may not be in existence otherwise so they do have a role to play but they are a tool and not a a full-fledged solution in themselves um and then engagement with rcie task force and other Statewide organizations mdhhs has recently convened a cie task force We Are One member and one voice in that uh in that task force working again collaboratively to line up all of the partners and move forward because that's really about the only way that we're going to overcome some of these issues is really kind of treating our partners as equal partners and moving forward together um so lots still being started out at the state level um uh whether or not we hie versus an hdu model certainly as we expand further and further into this space the hdu model seems to make a great of sense um next slide go on this is all you great well I can sort of talk about these experiences through the lens of a community partner um so just as a little bit of context I mentioned that we support seven Regional food banks across the state of Michigan and over 3 000 hunger relief agencies who have a myriad of uh data sharing initiatives with both social services our Department of Health and Human Services as well as healthcare partners that may be systems individual payers and uh and specific Health Centers and so we really are looking for approaches that leverage the um the current data exchange relationships that those organizations have and and are uh our our food banks have with those health care and Social Services Partners um we're seeking assistance with um obviously with creating governance models and Technical system design that can be streamlined and support all of these different projects that are going on as well well as looking at the financing piece which I think onc talked about at the beginning we are working with my hin specifically on how we can support our community-based organizations in use cases that support their pre-existing workflows so if they're doing a food security intervention with a health clinic already and there is a data sharing apparatus what we're trying to see is how we can leverage what's currently going on and add a layer of governance standards and out and workflows that can be vendor agnostic and support their current use so uh so I'm keeping an eye out for that serving on the cie task force I'm also one member of that task force and have seen uh what I think that if we have represented on that task force members from government industry history and community-based organizations and what I've seen is that the value proposition there for Community Information exchange is still evolving depending on which one of those sectors drives the conversation and as you can imagine financing understanding who the lead organization or agency is all of this effects sort of what data governance might be put in place at the state level and so that it really creates a situation where I think that the that the conversation shifts based on um based on the party that is um is really visioning that so we still have a lot of work to do but I am encouraged that we do have a cross-sector group assembled and that everyone's bringing their perspectives to the table next slide spot I think Dr kleichman I think you're picking up here oh okay well so for all of you on this call this sounds probably awfully high level and meta so what I want to do for the next minute or two is try to parse out where this may relate to local efforts to do work this is not a specific Michigan issue we've seen a lot of work done in Oregon California other states around trying to organize and sort of span the space from a community that wants to do something to a state that wants to coordinate and scale it problem here is that the Tail's been wagging the dog technology is easier than human systems change so in Michigan when we did the state Innovation model and when communities have moved forward to try to move information back and forth in cies technology is sort of easier to make a decision about than how you're going to share governance across many partners and many stakeholders when the power balances between Health Care with a mission to change this stuff and communities with a mission to try to serve people but not an organized structure come together we don't believe that Community Solutions can be imposed from top down we don't necessarily believe in Michigan at this point that a community can really organize itself around a single dominant vendor of service because people use information technology in different ways in different organizations so we had to decide that we were going to work with what was already going on in communities and then try to scale that up and that turns out to be incredibly difficult so we've tried to engage from our my hand lane of data governance conversations about some of those principles that might help to handle movement of data what principles matter how do you consent to sharing information for secondary use can we solve those simple data problems without a broader solution for how communities can organize and get the resources that they need to organize and have the time that they need to organize to participate so for us I think we can have a lot of conversation as time goes on but those are the issues that I wanted to frame our next speakers are going to talk about how this works out in a smaller community what I wanted us to focus on is some of the bigger issues when you try to scale and it sure feels like we have to be very careful about Equity not just data equity but equity and these are the tensions right how do you solve it locally how do you translate it Statewide how do you balance the needs of different vendors who see the space in different ways from care coordination to Medical Care to referral management how do you align across all of this and how do you make the value case for a community organization to invest time and energy in what's going to be a fairly long process that's where we're at next slide I think that's probably us I think that's I think that's the end of us and it's it's the idea that we're all walking this path forward in this tightrope um but I think when we start walking that tightrope together um not that you want to see 25 people on that tightrope but that may be what it takes to be able to really kind of um make meaningful change we'll be happy to answer many questions because we know that we were pretty high level here so as a conversation goes on we'll be around great thank you so much um to the team for sharing your approach and your learnings and perspectives and really appreciate the comments about scale um I know we are having technical difficulties with our chat and working furiously behind the scenes to correct it um we have not solved it just yet so we just want to pause here and normally we would take questions over chat oh it is solved okay someone chatted itself thank you um so we can pause here and take uh one to two questions for the myhin team and then we will have more time after our next presenters for further questions at the end yeah um we got a few things that I can Lisa can correct me when I make mistakes but a Health Data utility is a different thing from a Health Information Network um Health Data utilities are think of them as sort of um our power utilities turned to data transfer and management in an equitable way and that's kind of the vision for what we're hoping to accomplish in Michigan especially today as we're dealing with an ice storm a utility is a really great thing there was another question too related to that about some other stuff that we um if I can just scroll back up I'm having a hard time scrolling back it through mine but I think that there was a question here on what gravity standards yeah what is the cie testing yeah sorry like I said it's time the gravity project many of you may not know about that and and Emi advisors has been um at the very core of What's called the gravity project which is a national collaborative to develop standards for Content around social care problems what is a social care problem how do we code it how do we put it into a model of care so that participants from various sectors can better share information as we develop those data guidelines the gravity project is still working very hard on standardizing content and exchange standards so that Healthcare can better talk to social care and that's kind of the the guidance we're trying to follow in Michigan with multiple vendors so that we can make interoperability happen in a much more effective way than we were ever ever able to handle it just on the medical side I think it's I think it is important to really kind of call out that idea of the common care model as well and where Community fits into that not just kind of a one-way data dump from Healthcare to community and back to health care but rather kind of a really interactive and dynamic environment um Don I'm wondering if you want to feel the the question about what is the cie Task Force considering you actually sit on it yeah sure I'm happy to so in Michigan uh the Department of Health and Human Services their um their policy and planning office decided to convene a group of 24 uh Representatives across sectors who are interested in data exchange to support social needs care coordination uh in order to produce a report that would go to our Statewide Health I.T commission um in and they are in so what has happened is that happened about six months ago that this convening began and um and the idea was to take Statewide entities and to have discussions about what role the state might play in creating a Statewide health information exchange um strategy not necessarily creation of the health information exchange at the state level but trying to understand what's going on at the local and Regional level and what the state might do to support um scaling or replication or you know what's next for information exchange around Community Based information and so that's this entity that has been created that I talked a little bit about we're trying to figure out what we what the state's role could or should be in in uh a Community Information Exchange Christine I'm not sure not sure we have enough time I can either answer that offline or um your call yeah if you'd like to just give a quick answer and then expand in the chat that'd be great sure so right now our EHR vendors we we received a kind of a desperate plea to be able to kind of work with the uh social care referral vendors many of whom are are engaged by uh Healthcare entities and trying to kind of sort out um uh the role that that vendor plays in in Social care versus the EMR vendor whether or not you know all of all data is going to be recreated within an electronic medical record that was never really intended for um care coordination but rather for the treatment and billing of Medical Care uh and and so trying to encourage those Hospital systems and and uh organizations that employ an EMR vendor to really figure out what it is that they want to be able to do with it if they have a a referral offender what role is that referral offender going to play versus the role the electronic medical record is but certainly I do see a moving out to the electronic medical records was an interoperable referral standard is is is crafted great thank you so much um for for sharing that and folks feel free to continue to make comments and add questions in the chat like I said there'll be more time afterwards to continue um to continue the discussion and with that we're going to hand it over um to Malay to introduce our next speaker and our slide deck drops so let me pull it back up and we'll keep going Lee would you like to start the introductions and we'll have it back up in a moment yeah definitely thank you again Ryan um really great presentation and so now we will be hearing from Yuki Austin on our growing initiative and efforts design and enable seoh information exchange the presenters for this presentation will be video Lakshmi narayana um assistant director of research and Innovation at Dell Medical School Akram allperk director of research and evaluation at Ending Community homelessness Coalition on June crochet faculty and chief data scientist at Sentinel operations center in the department of population medicine at Harvard Medical School in the Harvard Pilgrim Healthcare Institute and the LEL de Oliveira director of research and Innovation at Dell medical school so I will pass it off to UT Austin thank you um and thank you for all the participants attending this webinar where we will um share our journey to develop Community governance for social determinants of Health the information exchange and um as mentioned I'll be joined by Vidya Akram and Ariel um and um I also want to thank the office of national coordinator uh especially our project team at onc and Emi advisors who have provided us this opportunity and have been a key partner in this effort so since the introductions have been made I think as we go through our team they will introduce themselves as well next slide so you saw this diagram earlier that is the basis of the sdoh information exchange cool toolkit recently released by onc and while we focus on the community governance aspect of this work uh the check marks on this diagram actually show other areas in which we have made significant progress in our community so as we look at all these components and based on our experience with health information exchanges or hies and the in the past 15 years or so it is quite clear that this continues to be an ongoing process where all these components influence each other and we need to constantly evaluate and adjust so just making that comment next slide um and to set the stage and context of our efforts in in our community consider some of these immediate challenges being faced by the Greater Austin area over the past few years it is one of the fastest growing Metro in the country and because of the influx influx of new residents and and businesses the home values have increased over 60 percent thus displacing many of the vulnerable populations including low-income workers um similarly homelessness is which is you know the tip of the iceberg of this phenomena but even that has shown a remarkable increase only in the last few years and we will link it to our work here a little later in the presentation so there is strain on other resources as well like Transportation Energy Water Supply and this increased growth is expected to continue with relocation of other big businesses in this area all this has increased just the present a pressure on social determinants of Health particularly for those who can least afford to deal with these changes thus causing increased disparities in the community as well which is something that we are all concerned about and brings us together next slide so as a community then our response was to think about a community-wide effort to co-create a data sharing ecosystem that can help individuals organizations and the broader Community to address these disparities and take care of our most vulnerables we worked on the idea of what a kind of model Community looks like and came up with this very person or family centered approach that you can see on the on the slide where social services are coordinated across the various providers and sectors for for that individual or family where we are able to close the loop of Social Service referrals between Healthcare social services and where we can use data to guide community-wide Solutions as well as to use our resources more efficiently next slide and and this is a journey as as was explained by our colleagues from Michigan as well it's not a one-time effort and what you see here is a timeline uh some of the early challenges of coordinating the social care were identified in our schools um and we will talk about it shortly and learning from that experience we simultaneously started developing the infrastructure that could facilitate such information exchange with Healthcare Systems as well which were an integral part of the whole family whole person approach there were other community efforts like connect ATX by United Way that became even more needed as as kovit hit our community so what we are currently bringing or or doing is basically bringing all these efforts together into an overall community-wide social determinants of health information exchange which combines infrastructure development with Community governance and identifies specific use cases where we can damage straight and learn the implementation of of such an exchange and how you can use it effectively next slide and none of this will be possible without obviously our partners local foundations generously supported uh this work our clinical Partners co-designed these systems with us in terms of how it integrates into electronic medical records um onc was a key partner in making sure that we are building a standards-based scalable model you know Emi advisors for partners gravity project private sector worked with us ehrs and Social Service platforms and Community organizations obviously helped in making this real so we are grateful to all our partners some of which are seen here but there are many more um so with that introduction let's get into the details of exactly how we built our community governance and I will hand it over to Vidya next slide to take it from there media awesome thank you engine we can go to the next slide but again as sanjim said this work started about 10 years ago in the school district again students and families getting Services by the community-based organizations is not a new challenge we know that they have been getting help with mental health tutoring mentoring academic enrichment in any of these areas the school districts have always worked with external Partners to provide support to their students what was missing is how do we identify where duplication of services is happening how do we ensure high-risk students are not slipping through the cracks how do we make sure that the families of these high-risk students are actually getting supported for these additional needs that they need in this community and is there a way for us to integrate it back so that we are able to see the impact of this social services on the student education outcomes that was the vision with which we entered into this work and I think as Mike very rightly stated technology grows faster and it's very easy problem to solve but human behavior and changing the workflows that the people follow is a challenge Austin ISD is a school district with 130 campuses 75 000 students enrolled in the school district so the first thing we worked on was what what is the governance we have about 250 plus community-based organizations that come and provide support to our students instead of creating a task force with all 250 Partners we hand-picked pilot partners that can help us design the governance one of them was a mental health partner one of them was providing services to students here for having incarcerated families they're from incarcerated families then we had picked a organization that provided not just one service but they provided multiple service and it was mostly focused on crisis management so we created a task force with partners coming in with multiple flavors and we included our funders of these organizations in that task force because ultimately these cbos have to go and Report the data back to the funders and the district wanted to find out from the funders what is it you are looking for when you're looking into these reporting and can the district take the burden off of the providers to generate these reports so they don't have to to recreate these reports or they don't have to massage the data to give it back to the funders and we also included parents in our task force because it's ultimately their trust their confidence for district sharing that data back with these community-based organizations and that's how we started this journey we work with the social service a vendor find help who's local to the Austin area and they helped us with designing the ysm that you see it's the youth services mapping that's the entry point for our community-based organizations so they go they have to get listed on this website and they then get through all the approval processes in the within the district and they get notified as an approved Austin ISD partner and then the community-based organization gets access to the reports or to student level data from our case management system and the case management system is where we are linking all of the sdoh interventions not just at the student level but also at the family level so the campus staff campus administrators are now able to see the whole child information when they are pulling up a student in the case management system it's work in progress we are in the seventh year we have 90 Community Based organizations that are providing us with that information even though we are at 250 plus organizations we know come and provide support it's not just about them being technologically savvy or having the capacity to provide the data it's also a lot of trust building that needed to happen the bigger questions were what is the district going to do with the data are you going to use it against us at the time of renewing our contract so all of this had to be solved in a very very um in a very critical way and lot of trust building activity had to happen I would say after seven years today our partners have come to the table asking us how can we help the district how can we help in propagating this to other partners how can we help you onboard other partners which I believe is a huge challenge because that's helping the district now where we don't have to make it a require environment but it's more of a partnership where they want to do is do this with us because they're seeing the benefits of getting the reporting back on the next slide you will see that a first year was very very heavily built on the governance again it was trust it was about when we have to open up a case management system that hosts all of the protected information to an external partner we had to do a lot of protocols we had to put a lot of processes in place before we could even get into this data sharing so we can we work with partners that provide direct services to our students we created an annual partnership renewal process with them because in a way it also reminds our partners what is the agreement about rather than just making an agreement for one time and keeping it for the whole whole time there and they are being a partner of the district we really wanted them to revisit all of these agreements every year that way when people change new people are onboarded they are familiar with this data sharing process and they know what they are signing up to do with the school district then we have students the cdos the community-based organizations come in and upload rosters and they get access to aggregated reports back this is available for everybody and the way we solved how can the district get access to this roster is by adding that language in the student registration form where the parents can sign off for the district's Gathering that participation roster from these cpos and then when these cpos are asking access to student level data that's where we get into the data sharing agreement with them and there is a parent consent we evolved where in the starting of the first year we said we have to collect consent every year that was not happening then we said the district needs to receive every single consent that was too much of a manual task on us so right now we are at a point where it's an ongoing consent for as long as the student is enrolled in this in that program with the CBO and the district will only provide spot checks to make sure that the CBO is collecting the consent so this is all our Lessons Learned in this journey of how we can make it easier for both the cbos for the parents and for us as a district now we are slowly starting to see the impact on the next slide you will see that the there is Improvement for students attendance for those who are enrolled in Services versus who are not enrolled in Services we are able to show reduction in discipline reference for those who are enrolled in services for those who are not enrolled in services and same thing with the star passing rate at the end of the year as well again these are not completely because we are still not having the picture of all 250 programs that the students are enrolled in it's work in progress and we are now working on how do we create Pathways how do we create use cases to show more of this impact can we see high high risk students families getting supported can we then see uh impact on student performance these are some use cases that we are working on it's work in progress and we are very blessed to have very strong Partnerships in this community to keep this going I'm now going to hand it off to eliel thanks video next slide please so I'm going to talk a little bit about the work we have been doing now in the health sector with some other lessons that we learned from the educational sectors so next slide uh like Andrew mentioned we decided uh we started early in 2017 building some ideas around and testing within the medical school in our community data platform that would allow us to then understand the better how to combine data about SEO Age and and more uh timely and and easily informed uh clinical care and informed clinicians and providers so what you see in this screen is the our Social and Health Information platform that we started putting together in 2019 which was trying to bring the records of longitude now records of individuals data from social services from clinical data and in such a way that delivers information at the point of care in an easy way that clinicians and providers can can react to it you see a visual here for Pediatric asthma that brought data from many sources to be able to summarize and in one way very easily how care can be provided I want to jump to the next slide quickly to detail a little bit how that was done you see here data coming from Clinical Partners from United Way like we talked about earlier which serves as an aggregator the 211 line in the community and from the school district that video just talked about all that coming together under the ship umbrella with the vision of other sources eventually come together in one place uh all of them using farming help but the idea of that the platform could really just integrate any sort of sub source of data and provide these visuals and dashboards and coordination at the point of care next slide please and but then in 2021 we received an award from morency of the Leading Edge acceleration projects to build what we called the fired social health and information platform with five ship which is basically getting the model that you just saw but instead of aggregating data centrally somewhere data State at the the end point through any will be accessed to the standardized gravity filed apis and allow the tech coordination to take place so next a slide and this is what you see here on these architecture diagram and how you envisioning this process to the the evolution of sdoh coordination so we basically place and ship this platform uh at the uh the health providers and the social services providers you see here in my after agency or at our local mental health authority at the food bank and and the hie and the referral systems also been uh enabled with filed apis all following the gravity standards and finally the patients provided with another project another solution that we built with onc in 2021 uh called fired up which is a mobile in web-based app where individuals get access to their data as in compliance with the 21st century cures act and is able to share that data with others but also the the platform allowed individuals to communicate with providers and better coordinate their own care so with this ecosystem in place what we can then allow is a direct communication using standards between providers and and patients and and cbos at the same time next slide please I wanted to make sure that as part of our governance is the engagement with the community that we put in place and and this is like highlights a little bit of that that we start with our community the strategy team at the medical school which uh uh has a a group of community leaders that advise on the scope of projects and how we engage the community and help us recruit uh the members of our community Advisory board that then is specific for a project we once we put together the community Advisory board that board help us then uh Define and uh how we're gonna engage the specific aspects of the project and what members of the community we're going to bring them to provide support and details and and guide the project itself and that leads us to create the community engagement Studios which are really made up of underserved in communities and individuals in the community duties from different communities where we learn about the design of the studies of the ethical considerations from different communities the strategies that you need to utilize so a whole process here that we utilize that sometimes take about are you also per project for us to understand how to better design our projects for to fit the needs of the communities next um this is a a visual of fireship for the pilot that we're working out with on NC that's on the way uh and and it's focused on its nap application coordination so you see on the left here a screenshot of the mobile app that the individuals are going to utilize on the right side the dashboard that the community health workers are utilizing Planet settings and there will be another one where the the coordinators at the food bank basically utilize to see end-to-end where individuals are in the process next in this diagram in the Nexus slides basically showing the workflow that we put in place after understanding the workflow with the food bank and as you can see here this is very specific to to this workflow but it gives us instant information about what is taking place which is quite important it starts with the patient download and the mobile app in clinical setting consenting two-day study and automatically they get the the needs assessment on the mobile device so they fill up the needs assessment themselves and when they submit the community health work in the clinical settings receive the answers and evaluate if they need uh is not the referrals the the community health worker then places the referral which is sent to the food bank and the food bank needs to accept the referral once they do uh the patient then gets uh automatically a set of Eligibility questions on their mobile device that they need to answer things like if you are U.S citizen or if you have someone else in the family that already received the benefits of snap and once you answer those basic questions and submit the food bank get the investors and they are able to evaluate if you should continue in the process or not but if you should continue they basically let you move to the next step which basically means two things one are you gonna get a request to select the dating time to meet with them in person or remotely and if you need a translation and so on and so forth but automatically once you select the date and time it automatically gets booked with the person at the food bank the second thing is the app automatically going to ask you to take pictures and upload the documents necessary for the application to be completed trying to prepare you for the meeting and once they need and complete the application we automate the app to send a message to the patient about 45 days and ask them if they have received a letter from Medicaid approving on the client the the application and if they receive the letter we ask them to take a picture again and send through the system to the food bank uh electronically so that if you decline we can follow up and get them back in the process and correct the application the important thing here is that because this is always standard apis based for us it's very important that we are able to understand where things may be uh falling through the cracks and and and not allowing individuals to complete the process which is not something that we have today with the referrals that are placed about 50 to 70 percent of the referrals that we place in our community we don't know where they are they do not get to the end and we believe that this ecosystem would allow us to have that better visibility um I this is important to highlight here because the next slide I'm going to talk a little bit about the governance and I would like to move to the next slide and how future use cases then gets designed and developed so you can see here this is our hie governance design and on the right side bottom part of the screen and you see several work groups of task forces that are exactly designed to work under the social health information platform and discusses things like what are the next big problems in the community that we want to address how those problems are going to be addressed at the point of care with the specific organizations involved whether it's a food bank or a Geo our homelessness community of housing providers how it's going to be implemented technically and how it's going to be disseminated across the community and once all that's defined how did we bring that to the HIV uh or cure group that has the legal operational and Technical capability to provide their proof if necessary whether it's so this is where we are in this stage and as you can see between the school district the health sector there's still a lot of learning to Define how Governors needs to happen across sectors uh they happen to have they have happened well within each sector and we're still working through building relationships and governance across sectors so with that said I want to turn on to Akron to describe a little bit the work that we are doing with the homelessness uh uh Coalition in our communities and how we have understood our governance aspects related to that program thank you Elio um I'll try to be very quick because I know we're trying to wrap up to get to q a um next slide please um so I I work at Echo and and um to just give you a quick uh overview of what we do you know we we coordinate a lot of the homelessness uh Services here in Austin and Travis County we're the lead agency of the Continuum of Care uh but I think most relevantly for this conversation is that we administer and we manage the centralized database that all the service providers use um here locally and it's hmis is the name of the database that has been around for I think you know communities have been using hmis since the late 90s across the country um and so there are dozens of service providers that use hmis here in in Travis County uh in any given year we have about 10 to 13 000 people who have any interaction at all with any of the service providers and so we have information on them in hmis uh the the main I think takeaway here is that you know hmis is used mostly for care coordination among homelessness Services providers um and and I think that's really the Crux of the challenge here is that although hmis is is useful for that purpose um it is it is used only among service providers who are providing um Direct Services to people experiencing homelessness and and one of the challenges that we and we wanted to address is how do we understand people's medical needs their health care needs uh more so than we than we do now with just with hmis data and so in the last couple of years we have been working with the medical school and Connexus our local hie here um to see how we can do you know how we can share data between hmis and Connexus so the big question was can Healthcare Providers share Phi with a third party that is not a health care provider we are not a healthcare health health care provider um and so under you know using some guidance from the office of civil rights and HHS um you know we there was some guidance there that we a provider could share Phi about individuals to service providers that you know serve people who are looking for housing or look you know or needs other social services and so using that data guidance or that guidance from OCR connects this approved data sharing through its data released task force and board of directors using this guidance hi hmis has its own consent process people can share or not share their information outside of hmis so we take that into account but but again you know we were able to in the last year and a half or so be part of Connexus and and be able to do some of the data sharing between hmis and Connexus next slide please just want to go through quickly kind of the impact of this the short-term impact of this data sharing you know as I mentioned earlier we use hmis um quite a bit to understand people's needs uh when it comes to Health Care needs you know all of that is self-reported data and so I think what we're trying to do here is to move move to understanding a better understanding Healthcare utilization and then also better understanding medical vulnerabilities of folks and so you know as a result of us having Connexus data we're able to see utilization of services um among people experiencing homelessness we can see here just as a quick snapshot that people who are living unsheltered are more likely to use an ER or have an ER encounter than people who are living sheltered or living in in one of the shelters here locally um so that's just one of the things that we're able to do with this but and then next slide I think what what we would like to do in the long-term impact of this and this is you're still in the early stages of this is really to have better care coordination between housing providers and medical providers to have more accurate evaluation of the benefits of housing to healthcare outcomes we have and I'll just share here and I'll end here uh I'll share a little bit about this at home initiative

2023-03-03 18:12

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