Cross-Sector Data Sharing to Address Health-Related Social Needs: Lessons Learned from the Accountable Health Communities Model

Cross-Sector Data Sharing to Address Health-Related Social Needs: Lessons Learned from the Accountable Health Communities Model

Published: Oct 11, 2022
Publisher: Centers for Medicare & Medicaid Services

Barbara Singhakiat

Maya Talwar-Hebert

Shauna Robinson

Key Findings
  • Prioritizing community and patient voices is essential to ensuring that data sharing initiatives are trauma informed and do not cause harm.
  • Discussing data on health-related social needs (HRSNs) with community partners allows bridge organizations to understand findings and explore how systems and structures can contribute to identified inequities in needs and access to services.
  • Providing HRSN screening data helps health care providers tailor care to patients’ social context. However, health care providers were uncertain about how to best use screening results to inform clinical care and whether sufficient resources are available to address HRSNs.
  • HRSN data is essential to community-based organizations’ (CBOs) efforts to apply for grants, inform program design, and understand the needs of their community. CBOs benefit from HRSN data specific to the populations and patients they serve. However, as a result of new referrals from the AHC Model, CBOs experienced increased workloads while still working with limited resources.

Data sharing between clinical and community partners is a critical component of understanding and addressing health-related social needs (HRSNs), such as housing, food, transportation, utilities, and interpersonal violence that affect individual and community health. Effective data sharing can streamline referrals and improve care coordination for patients, as well as enable more systematic reporting and analysis of HRSNs at the community level. From 2017 to 2022, the Centers for Medicare & Medicaid Services (CMS) supported Accountable Health Communities (AHC) Model awardees, known as bridge organizations, to screen Medicare and Medicaid patients for HRSNs, refer patients to community services to address identified needs, and offer community service navigation to those eligible. Mathematica conducted a series of focus groups and interviews with AHC bridge organizations and their partners to explore whether and how HRSN data were shared with clinical and community partners, used to inform clinical care, or used to advance equity. This summary report describes data sharing efforts, promising practices for advancing equity using data, key challenges in sharing data with health care providers and community-based organizations, and lessons learned.

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