For the last two years, I’ve witnessed first-hand the growing movement of data-driven and multisector ventures to improve community health. The 15 communities that formed AcademyHealth’s Community Health Peer Learning (CHP) Program represent a cross section of population health improvement efforts across the country all working to link critical information from within and outside of health care. Their innovative data sharing efforts aim to address some of today’s most persistent health challenges – from prevention and management of pediatric asthma to care coordination for at-risk individuals facing housing insecurity.

Their ambitious objectives won’t be realized with a one-time grant or investment of local resources. But as many communities in the CHP cohort are now transitioning to the next phase of their work, several recent funding awards signal great promise for the future of their community-based efforts, and for us all.

New Orleans Continues to Build Out Data Sharing Capacity to Improve Community Health

As a part of CHP, the Crescent City Participant Community (CCPC), administered by the Louisiana Public Health Institute (LPHI) with joint leadership from other community partners, sought to improve care and reduce costs for those with serious and persistent mental illness who often interact with the criminal justice system and require emergency care because their conditions are poorly managed. Leveraging the Greater New Orleans Health Information Exchange (GNOHIE), the team worked with these sectors to undertake a data mapping process that helped to orient different partners to the movement of patients/clients through the various systems, and to discover which data elements were collected, when, and by whom. This increased data sharing and analysis among key partners has helped them to better identify opportunities for improvement, and plan data-driven interventions for this population as well as others.

As an example, one opportunity for improvement using increased data sharing is in the area of mobility for residents suffering from chronic disease. Thanks to a new funding award as part of the BUILD Health Challenge 2.0 cohort, the team plans to build an integrated health equity data system to address persistent mobility barriers that underlay disparities in chronic disease rates in the Claiborne Corridor. By collecting and integrating clinical, social, and community infrastructure data, this team will provide focused, geographically specific analyses to inform population health and equity efforts—and ultimately policy recommendations.

These efforts with this new population will not only support further expansion of their multi-sector data integration strategy, but also provide strong momentum as they move into even more data-driven population health improvement areas. For example, the Louisiana Department of Health and Hospitals is now working with LPHI to grow the GNOHIE network and to improve data quality and health information exchange services.

New Funding Supports Rural California Community’s Data-Driven Efforts to Address Substance Use Issues

Another CHP community in California, the North Coast Health Improvement and Information Network (NCHIIN), a not-for-profit health information exchange, partnered with the Humboldt County Department of Health and Human Services Social Services (DHHS-SS) to reduce emergency department utilization among high-need “super-utilizer” populations grappling with chronic behavioral and mental health issues, as well as insecure housing. Given the variety of entities serving these populations, the team did a tremendous amount of upfront work to make sure that all were engaged in and comfortable with the informed consent processes for data sharing.

As a result of this upfront work, the team expanded the data sources flowing via North Coast’s health information exchange, and leveraged a care coordination platform to facilitate data sharing among health care, social, and human service providers. There are now electronic data flows between the county, NCHIIN, case managers, county Homeless Management Information System (HMIS), and a subset of hospital EDs. 

In the last several months, this team secured a grant to be part of the California Accountable Communities of Health Initiative (CACHI), and recently received significant support from the Well Being Trust to leverage their prior work and launch the Humboldt Community Care Trust - Humboldt County’s Accountable Community for Health. Informed by the structured collaboration between health care, public health, and a variety of partners outside the health care system, the Humboldt ACH will initially focus on addressing issues related to substance use disorder, a topic that was overwhelming identified as one of the County’s most urgent and pervasive health problems.

These are just two examples of the success I’ve seen communities achieve by partnering with and learning from a diverse array of funders, researchers, public health practitioners, care providers, social service organizations and other “boots on the ground” community change agents. While the perpetual drive to advance means this progress isn’t always celebrated as it should be, it’s exciting to see the hard work of these communities rewarded with additional support.

I very much look forward to following the progress of these and other community initiatives in the coming years, and to working at the intersection of research, policy, and practice to harvest, synthesize, and share their lessons and accomplishments through the nationwide learning collaborative All In: Data for Community Health. All In is making an active push to grow this network by inviting other community-based transformation initiatives, so if you’re interested in receiving monthly updates including news about local collaborations, practical resources, and upcoming events, make sure to sign up for the All In newsletter.

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