Participants in the Community Health Peer Learning Program

With growing recognition that individual and population health is very much shaped by the characteristics of where people live, work, and play, communities nationwide are looking for new ways to address these social determinants of health. In partnership with the Office of the National Coordinator, AcademyHealth sought to build community capacity in this area through the Community Health Peer Learning (CHP) Program, which in January 2016 awarded 15 communities with grants to work towards improving community health through the expanded collection, exchange, and use of health data.

The CHP communities focused on diverse populations, and addressed a number of health improvement issues, ranging from pediatric asthma to improved care coordination for people  with complex behavioral and mental health needs.

All Chicago Making Homelessness History
All Chicago Making Homelessness History, a not-for-profit organization dedicated to ending homelessness across Chicago, and the University of Illinois Hospital and Health Sciences System (UI Health) are partnering to engage in the CHP Program. The team will work to improve care coordination for Chicago residents who are housing insecure or homeless by integrating data from UI Health’s electronic health records with information about housing status from the Homeless Management Information System managed by All Chicago. UI Health and All Chicago anticipate that these efforts will lead the way for greater integration of housing, health, and human services delivery systems at a national level. 
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Children's Comprehensive Care Clinic
The Children’s Comprehensive Care Clinic is a not-for-profit organization dedicated to finding innovative approaches to pediatric health challenges.  With the support of the CHP program, the Children’s Comprehensive Care Clinic will work with its partners to improve care for families of children with medical and behavioral complexity throughout multiple counties in the Austin, Texas area. Through collaboration among multiple sectors including health care, social services, community-based organizations, and education, they will build and provide a patient-controlled common technology platform. The effort aims to bring together individuals and entities involved in the care of a child, with the patient and family at the center, and anticipates developing a sustainable, integrated, participatory health care data ecosystem. 
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Cincinnati Children's Hospital Medical Center
The Cincinnati Children’s Hospital Medical Center (CCHMC) is a not-for-profit organization working to improve child health and transform delivery of care through fully integrated, globally recognized research, education and innovation. In an effort to identify hot spots of poor child health and to understand the underlying social determinants of health, they will work with the CHP Program to reduce inpatient hospitalizations for pediatric patients with the use of electronic health records and geographic information systems in its community. The use of data across sectors will improve CCHMC and its partners’ ability to identify and address root causes of poor health outcomes within the community. CCHMC anticipates that work undertaken during CHP will translate to other Cincinnati neighborhoods in the future. 
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Dignity Health Foundation
The Dignity Health Foundation, a not-for-profit organization that aims to improve screening and treatment for postpartum depression by engaging pediatricians, obstetricians, mothers’ primary care providers, and others key stakeholders in health care, has joined the CHP program. To address the link between maternal and child health by reducing stigma and increasing screening and treatment of postpartum depression, they will foster a collaboration between the Marion Regional Medical Center and a number of Community Partners serving the Santa Maria Valley in southern California. With support from the CHP Program, the Dignity Health Foundation will develop a postpartum depression toolkit, which would include a directory for web-based resources, and processes for data sharing and training materials for community health workers, that can be shared with other health systems. 
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Louisiana Public Health Institute
The Crescent City Participant Community (CCPC) is administered by the Louisiana Public Health Institute with joint leadership from the City of New Orleans Health and Police Departments, the City of New Orleans Homeless Court, Metropolitan Human Services District, the Orleans Parish Forensic Mental Health Coalition, the Orleans Parish Sheriff’s Office, and the Partnership for Achieving Total Health, Inc.  Through its collaboration with the CHP National Program Office, the CCPC will be working to use health information technology to share management and coordinate care among participant entities - aggregating data from electronic health records, proprietary and public community-level records, public health information, and the Greater New Orleans Health Information Exchange.  The CCPC aims to identify and intervene for the severe and persistently mentally ill and other vulnerable people that are high-utilizers of the criminal justice system, emergency departments, emergency medical or crisis response services, psychiatric facilities, and social services agencies. 
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North Coast Health Information Network
The North Coast Health Information Network, a not-for-profit health information exchange has partnered with the Humboldt County Department of Health and Human Services Social Service (DHHS-SS); through the CHP program, they will work to reduce emergency department utilization by the indigent, high-need, super-utilizer population by 15 percent over the course of their participation in the CHP program. In order to do so, they will build an interface between the DHHS-SS Homeless Management Information System and North Coast’s health information exchange to share data from electronic health records, and public and private records, social services case managers will receive alerts about clients’ health center/hospital visits for follow-up care coordination. The organization will aim to decrease emergency department utilization by 25 percent over time and expand the data exchange to other programs and social service organizations. 
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Providence Center for Outcomes Research and Education
The Providence Center for Outcomes Research and Education is a not-for-profit health policy research shop committed to improving community health.  Their CHP project will be based in a multi-county region in Southwest Washington State, and will bring together diverse sectors including academia, education, housing, health care, and criminal justice. With the support of the CHP Program, their team will build a shared data system that will aggregate public records, insurance claims, and public health data for community-based population health management. 
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University Hospitals Rainbow Babies & Children's Hospital
University Hospitals Rainbow Babies & Children’s Hospital is a full-service children’s hospital and pediatric academic medical center – a not-for-profit organization that uses advanced treatments and innovations to deliver pediatric specialty services for 740,000 patient encounters, annually. With the support of the CHP Program, they will work to prevent and manage the childhood asthma disease burden in target neighborhoods in Cleveland, Ohio. Fostering partnerships among the health care, public health, housing, social services, environment, and criminal justice sectors, the organization will use data from electronic health records, and public and private records, and Medicaid claims to integrate existing pediatric longitudinal social, environmental, educational, and clinical data. Through this work, they anticipate the ability to create an accountable care community to collectively improve the health and wellness of these Cleveland neighborhoods.  
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Vanderbilt University Department of Health Policy
The Vanderbilt University Department of Health Policy is committed to bringing together a broad group of health policy scholars devoted to developing health policy solutions. Through the CHP program, they aim to decrease infant mortality rates by developing a data-sharing network to study predictors of infant mortality and identify at-risk mothers and infants. With shared data from various sectors, the organization will be able to aggregate and analyze disparate data that will allow real-time identification of at-risk pregnant women and referral to specific and appropriate interventions. By engaging new community partners and including additional data, they anticipate improving their predictive model until they can correctly place 95 percent of prior years’ infant deaths into the highest tercile of risk. 
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Vermont Child Health Improvement Program (VCHIP), University of Vermont
The Vermont Child Health Improvement Program (VCHIP) of the University of Vermont College of Medicine’s Department of Pediatrics is a population-based maternal and child health services research and quality improvement program. Through its participation in the Community Health Peer Learning Program, VCHIP will create an electronic shared plan of care (e-SPoC) for families with children and youth with special health care needs. This family-centered system will aim to simplify the management of each child’s multiple systems of care into adulthood through information from electronic health records as well as data on economic, environmental, and social determinants of health. 
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Essential Access Health
Essential Access Health (EAH) champions and promotes quality sexual and reproductive health care for all. EAH achieves its mission through an umbrella of services, including clinic support initiatives, advanced clinical research, provider training, patient education, advocacy and consumer awareness, and data-driven performance measurement and quality improvement. EAHwill contribute their expertise in data aggregation, technical assistance, and performance measurement and data dissemination. EAH staff is experienced in processing large quantities of data, as well as creating and maintaining data reports from different electronic health records systems. They use these data to populate web-based dashboards where participating agencies can view their performance on a core set of measures and get recommendations on possible corrective actions to improve their results.
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Greater Detroit Area Health Council
The Greater Detroit Area Health Council (GDAHC) is a not-for-profit organization that has extensive knowledge of data analysis, and performance measurement and data dissemination. GDAHC currently works as one of seven initiatives across the country focused on the use of electronic health records and supporting data to identify population-level issues, such as antibiotic use for viral infections and appropriate screening for Vitamin D deficiencies, with a goal to improve quality, health, and efficiency. They are dedicated to transparency in data sharing, and have successfully launched a system of multi-payer data measurement and public reporting of physician performance on their website (myCareCompare.org). In addition, they successfully provide aggregated individual physical level data to physician organizations to guide quality improvement.
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Minneapolis Heart Institute Foundation
The nonprofit Minneapolis Heart Institute Foundation works to improve the cardiovascular health of individuals and communities through innovative research and education, and is well-versed in cross-sector collaboration.They will share lessons learned during the development, implementation, and evaluation of Hearts Beat Back: The Heart of New Ulm Project – a 10-year community-based initiative to reduce heart attacks in New Ulm, Minnesota. They successfully collaborated with partners in various sectors to utilize data from electronic health records, community health screenings, community needs assessments, and environmental assessments to make health-conscious changes throughout New Ulm. They are committed to sharing their experiences and best practices with other communities throughout and beyond Minnesota.
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San Diego Health Connect
The San Diego Health Connect (SDHC) is a Health Information Exchange (HIE) that successfully designed and implemented a regional health information organization in the San Diego and Imperial Counties. As a part of the CHP Program, they will partner with Be There San Diego (BTSD), a multi-stakeholder collaborative experienced in improving population health with a focus on cardiovascular disease. With extensive expertise in technical infrastructure and data exchange, SDHC is an active trading partner with The Sequoia Project, a national HIE, and has partnered with San Diego County Health and Human Services to facilitate automated, electronic transmittal of relevant patient data for monitoring public health and delivering services where needed. In addition, their patient indexing system allows them to positively identify 95 percent of the region’s adult population, and their standards in naming and information records have increased patient matching to over 95 percent. BTSD, in turn, excels in sharing and comparing data in a collaborative learning environment to identify and promote best practices and improve health outcomes.
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The University of Chicago Medicine
The University of Chicago Medicine will provide expertise in data integration to the CHP Program. As the anchor health care institution on the south side of Chicago, they convened and collaborated with community partners to address critical health issues in their communities. Through their Medical Home Connection program, they leveraged partnerships with community health centers to use consistent messaging when educating emergency department utilizers on the value of using medical homes for ongoing care. Patient Advocates scheduled follow up medical home visits for patients who were discharged from the emergency room. Through an electronic portal they sent real-time information to the health centers informing them of the patients emergency room visit and follow up appointment. The program successfully increased the average show rate to follow up appointments from 35 percent to 60 percent. With the adoption of an electronic patient information portal integrated with the electronic information system, the program expanded. With the use of data from multiple sources the collaborating partners have implemented several additional population health management programs.
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