The following five Data Across Sectors for Health (DASH) awardees are participating in a 6-month initiative called CIC-START (Community Impact Contracts – Strategic, Timely, Actionable, Replicable, Targeted). DASH CIC-START aims to help local collaborations catalyze their efforts to share and use multi-sector data to improve community health.
Each awardee is receiving up to $25,000 to execute a time-limited activity that builds their capacity to engage partners from multiple sectors in planning or implementing an integrated data system or designing health interventions based on shared data.
- Eureka, CA: Building a System – New Partners, New Sectors, New Data is adding new organizations, sectors, mental health client summary data, and facility alerts to their care coordination and alerts notification system. Led by North Coast Health Improvement and Information Network.
- Austin, TX: Community Data Ecosystem as a Vehicle for Care Integration is designing a “shared care plan” that imports goal statements and care instructions from different members of the interdisciplinary care team into an existing patient-controlled application. Led by Children’s Optimal Health.
- Ontario, CA: Healthy Ontario Health Equity Data Project is leveraging its existing partnerships to create a shared definition and action plan for health equity related to the causes and drivers of obesity in Ontario, CA. Led by Partners for Better Health.
- Portland, ME: Maine’s Homeless Health Information Planning Collaborative is bringing together multi-sector stakeholders to explore sharing data between the homeless and health care service sectors, providing recommendations for data governance and consent management. Led by HealthInfoNet.
- Chicago, IL: Refining Data Exchange Platform is refining the algorithm and prototype for a platform for exchanging data between hospitals, health care payers, and the county’s Homeless Management Information System. Led by All Chicago Making Homeless History.
In February 2016, DASH awarded ten grants, totaling $2 million, to support projects that improve health through multi-sector data sharing collaborations. These DASH grantees received up to $200,000 each to develop and implement multi-sector data sharing projects.
Allegheny Data Sharing Alliance for Health
Allegheny County Health Department, Pittsburgh, PA
The Allegheny County Health Department (ACHD) is forming the Allegheny Data Sharing Alliance for Health—a connected data warehouse that combines data from multiple sectors to create a more complete picture of the factors impacting the cardiovascular health of the county’s 1.2 million residents. The collaboration will merge existing data sets from five sectors: public health, human services, economic development, healthcare, and transportation. Once amassed, the data will be exported to a modeling platform, the Framework for Reconstructing Epidemic Dynamics (FRED). Ultimately, a geographically accurate model of the complex distribution of cardiovascular disease risk factors in the county will enable the community to test the potential impact of various interventions.
Altair Accountable Care for People with Disabilities
Lutheran Social Service of Minnesota, St. Paul, MN
Altair, with Lutheran Social Service of Minnesota as fiscal sponsor and lead member, envisions an e-Health infrastructure that fully integrates primary care (including supplemental mobile health services), behavioral health, and social services to improve the quality of life of people with disabilities in the Twin Cities. The project is bringing behavioral health providers into a state certified Health Information Exchange (HIE), enabling care teams to proactively assess the behavioral health needs of people with disabilities within a Minnesota Accountable Care Organization (ACO).
Baltimore Falls Reduction Initiative Engaging Neighborhoods and Data (B’FRIEND)
Baltimore City Health Department, Baltimore, MD
The Baltimore City Health Department (BCHD)—working with a collaborative that includes the Mayor’s Office, CRISP (Maryland’s HIE), community-based organizations and nonprofits, and faculty at Johns Hopkins and the University of Maryland—is leading a city-wide effort to reduce falls among residents age 65 and older. B’FRIEND is creating a real-time data surveillance system that will track fall-related emergency department visits and hospitalizations. The project is also integrating core medical data with other health, housing, environmental and social service data related to fall risks. Data analyses will be used to align community programs, direct place-based interventions, develop new interventions, and inform a public health campaign.
Childhood Lead Paint Hazard Data Sharing
Chicago Department of Public Health, Chicago, IL
The Chicago Department of Public Health (CDPH) with its partner at the University of Chicago’s Center for Data Science and Public Policy created a predictive model that helps identify young children at risk of being lead poisoned in homes with lead paint. The model provides an opportunity to prevent lead paint exposure through proactive home lead inspections and blood testing at an earlier age. The predictive model combines data from multiple sectors including public health, census, buildings and the county assessor’s office to create realtime interfaces that identify where at-risk children live. CDPH housing inspectors will be alerted to inspect the homes of at-risk children for lead paint hazards either through an application or by physicians at community health centers through electronic health records (EHR).
Food for Health: Coordinating Care Across Sectors to Improve Health among Vulnerable Populations
Parkland Center for Clinical Innovation, Dallas, TX
The Parkland Center for Clinical Innovation, the Parkland Health and Hospital System, and the North Texas Food Bank and its partner agencies are leveraging the Dallas Information Exchange Portal to improve the diet and nutrition of patients who experience food insecurity and have been diagnosed with chronic diseases like hypertension and diabetes. The project will improve multi-sector care coordination by providing hunger relief agencies with a real-time, electronic one-page summary of clients’ medical and social history so that case workers can recommend appropriate nutritional choices and facilitate chronic disease self-management. Relevant information will also be shared with health care providers at Parkland to enhance their understanding of patients’ needs.
King County Data Across Sectors for Housing and Health
Public Health – Seattle & King County, Seattle, WA
Connecting data across health and housing has the potential to improve the health of residents living in low-income housing in King County. For the first time, Public Health – Seattle & King County is partnering with local housing authorities to link housing data with Medicaid claims records. The result is de-identified data that can provide key information about the health issues facing residents. This information can then be used to develop prevention programs—such as the use of community health workers—to address specific health needs of the resident community. This approach is part of King County’s Accountable Community of Health—a regional partnership committed to working in new ways to improve health and health care.
Maine Data Across Sectors for Health
HealthInfoNet, Portland, ME
HealthInfoNet (HIN), a nonprofit that serves as the statewide health information exchange (HIE), is leveraging the HIE and a real-time predictive analytics system to integrate electronic health record and social determinant data across three critical access hospitals, seven federally qualified health centers, and two Community Action Agencies (CAAs) in Maine. The HIE and predictive modeling programs will be deployed to identify the most complex, high-risk patients so that care management teams can connect them to appropriate community services. In particular, the project team is identifying the most appropriate datasets related to social determinants of health to incorporate within the HIE.
Neighborhood Tabulation Areas: Enhancing Community Health Improvement Capacity in NYC Through Shared Information at the Small Area Level
NYC Department of Health and Mental Hygiene, New York, NY
The New York City Department of Health and Mental Hygiene (NYC DOHMH) and its partners are creating a comprehensive dataset that encompasses small area health profiles that will reflect the impact of social, economic, and other factors on community health outcomes. Project analysts are geocoding and analyzing newly obtained and existing data from multiple sectors at the Neighborhood Tabulation Area (NTA) level (approximately 30,000 residents), increasing granularity to help identify and refine specific health needs. The NTA-level profiles will enable enhanced analysis, monitoring, and planning to promote the health of all New Yorkers and reduce health disparities in high-need communities.
Using a Connected Information System to Enable Spontaneous, Shared Community Treatment of Adults with Severe Mental Illness
Center for Health Care Services, San Antonio, TX
On behalf of the Community Medical Directors Roundtable, the Center for Health Care Services (CHCS) is leading a multi-sector effort to create a connected information system that integrates physical and behavioral health care data into Healthcare Access San Antonio (HASA), a regional health information exchange (HIE). The system will enable critical sectors—including law enforcement, hospitals, and homelessness services providers—to rapidly identify people in crisis and notify CHCS staff through real-time HASA alerts. This will allow behavioral health providers to intervene earlier and prevent inappropriate hospitalization or incarceration. Furthermore, when a patient arrives in the emergency department exhibiting psychiatric symptoms, HASA participating organizations will be able to access an individualized Community Treatment Plan to help direct the patient’s course of care.
White Earth Nation WECARE Implementation Project
White Earth Reservation Tribal Council, Omega, MN
The White Earth Reservation Tribal Council is expanding implementation of WECARE (White Earth Coordination, Assessment, Resource and Education), a care coordination database system that provides an efficient and effective way to link families on or near the reservation to the services they need. The project is using RiteTrack software to improve care coordination, enabling connections between primary care, home health, education, early childhood programs, and human services in an accountable care-like organization. Clients complete a universal intake assessment indicating their interest in a wide range of community services, creating an electronic alert referral for appropriate programs to address the social determinants of health.