Photo by: John Corbin, Garrett County Health Department
Imagine a world where doctors, public health officials, police officers, social workers, and other community stakeholders were all sharing their data in an effort to improve the health of the people they serve.
Across America, many communities are making this vision a reality—but not without struggles along the way. These local collaborations are somehow able to overcome turf wars, legal issues, technology challenges and more to ultimately end up with integrated data systems that allow them to be more efficient and effective at improving people’s health.
So what’s their secret? What have they learned that could help other communities fighting the same battles?
On the new All In: Data for Community Health podcast, we will talk to local leaders who are tackling these challenges head on and going “All In” to collaborate with other sectors to systematically share data to improve community health.
Children’s Comprehensive Care Clinic was funded by the Community Health Peer Learning Program (CHP) to provide a patient-controlled common technology platform that improves care coordination for families of children with medical and behavioral complexity in Austin, TX. The platform brings together individuals and entities involved of the care of the child, with the family at the center, to develop an integrated health care data ecosystem. Podcast host Peter Eckart joined Rahel Berhane, MD, Medical Director at Children’s Comprehensive Care Clinic and Susan Millea, PhD, Community Systems Analyst at Children’s Optimal Health, during a site visit for their new CIC-START project, which is designing a “shared care plan” that imports goal statements and care instructions from different members of the interdisciplinary care team into the existing patient-controlled application.
Podcast host Peter Eckart joined Evette DeLuca, Executive Director of Partners for Better Health, during a site visit for their new CIC-START project, which is leveraging multi-sector partnerships to create a shared definition and action plan for health equity related to the causes and drivers of obesity in Ontario, CA. The project will integrate its existing data platform into local health systems’ electronic medical records to provide a packaged screening intervention for health equity at hospitals and health centers across Ontario. Partners for Better Health was previously funded by the BUILD Health Challenge to systems and policy for long-term sustainability while expanding Health Hubs and environmental solutions across the City of Ontario.
Dr. Andy Beck is a pediatrician at the Cincinnati Children’s Hospital Medical Center, where he conducts research focusing on population-level health disparities and forms partnerships with community organizations to reduce risks related to poverty. He sees patients as a primary care and hospitalist pediatrician. Dr. Beck joined the podcast to discuss a project that is addressing disparities in hospital bed days for kids with asthma and respiratory issues in Cincinnati’s Avondale neighborhood. The project, which was partially funded by the Community Health Peer Learning Program (CHP), a founding All In partner, integrates inpatient hospitalization records and geographic information systems to better understand and address underlying social determinants of health.
Stephanie Fenniri, senior community partnerships manager at the Parkland Center for Innovation (PCCI) and Dr. Yolande Pengetnze, medical director at PCCI and a board-certified pediatrician, joined the podcast to discuss a DASH-funded project that is connecting hospitals and food banks in Dallas, Texas to improve the nutrition of patients who experience food insecurity and have been diagnosed with chronic diseases like hypertension and diabetes. They are developing a network of health care and community-based organizations in the Dallas region that are sharing information through the Dallas Information Exchange Portal.
Jessica Solomon Fisher, MCP, is the Chief Innovations Officer at the Public Health National Center for Innovations (PHNCI), the newest partner to join the All In network. Fisher joined the podcast to explain how PHNCI is working to make innovation a useful tool for public health departments rather than a buzzword. She shared examples of innovative initiatives happening in communities across the country and gave advice for overcoming the many challenges to driving meaningful change. PHNCI continues to work to foster a multi-sector learning community to help identify and test new and innovative practices to improve public health capacity.
Podcast host Peter Eckart met up with Shelley Argabrite, health planner for Garrett County Health Department, while they were both at the Communities Joined in Action conference in Atlanta, GA. Shelley explained how the health department has developed a digital data platform that has transformed the way they engage hard-to-reach rural residents in community health planning, making the process more equitable and using multi-sector data to drive decision-making. She also shared how, with funding from the Public Health National Center for Innovations (PHNCI), Garret County Health Department is working to make the digital tool available to other communities across the U.S.
Podcast host Peter Eckart joined Jodi Hardin, Co-Executive Director of Civic Canopy, during a site visit for their DASH CIC-START project, which is using a Results Based Accountability methodology to harness community member and partner perspectives and move from talk to action around measures, indicators and data-informed decision-making. They are part of a multi-sector collaboration called East5ide Unified that aims to ensure all children and families in East Denver are valued, healthy, and thriving. As part of their CIC-START project, East5ide Unified is developing a framework to document shared results and measures of success they aspire to achieve and identifying the routines and structures needed to utilize the data to meet their goals.
Josie Williams, Project Coordinator at the Greensboro Housing Coalition, joined the podcast to discuss a BUILD-funded project called “Collaborative Cottage Grove” that is fostering resident-led efforts to improve poor housing conditions that are leading to asthma-related emergency department visits in the Cottage Grove neighborhood of Greensboro, NC. Motivated by a desire to improve conditions in neighborhoods similar to the one she grew up in, and guided by resident voices, Williams is working with multi-sector partners to map asthma hospital visits and housing condition data to identify areas in need of support. The collaborative is also in the process of developing an electronic referral system to link families with asthma education and housing assessments.
Leah Hendey, MPP, Senior Research Associate at the Urban Institute, joined the podcast to reflect on her experiences co-directing the National Neighborhood Indicators Partnership (NNIP), a nationwide effort to advance the use of neighborhood-level data to drive local decision-making. NNIP is led by the Urban Institute and a network of 32 partners representing local data intermediaries across the country. Hendey discussed the role local data intermediaries play in their communities, explained how neighborhood-level data can be used to understand and address issues of health equity, and shared examples of communities that have successfully used neighborhood information systems in innovative ways to solve pressing public health challenges.
Karis Grounds, MPH, Vice President of Health and Community Impact at 2-1-1 San Diego, joined the podcast to discuss how she is supporting the strategic development of San Diego’s community information exchange (CIE), a technology platform that is enabling data sharing and collaboration between health and social service providers to deliver person-centered care and improve health equity. Grounds shared strategies for aligning multi-sector partners around a shared language and an integrated technology platform to deliver enhanced care coordination. She also discussed how 2-1-1 San Diego is spreading its impact by sharing practical tools to help other communities make progress towards implementing a community information exchange.
Applying a health equity frame during every phase of the data process can help communities understand and address the root causes of persistent health disparities. Marijata Daniel-Echols, PhD, Director of the Center for Health Equity Practice at the Michigan Public Health Institute (MPHI), and James Bell, MSW, Director of Policy & Engagement at MPHI, joined the podcast to explain the ways in which the development of research questions, data collection and analysis methods, and reporting strategies can either promote or thwart health equity. They also shared strategies and examples of how communities can capture and lift up diverse perspectives through a combination of data and storytelling.
This episode features Martin Love, CEO and Jessica Osborne-Stafsnes, Program Manager at the North Coast Health Improvement and Information Network (NCHIIN) – a non-profit health information exchange in Humboldt County, CA. NHIIN focuses on exchanging information across multiple sectors – including social care, medical care, behavioral health, criminal justice, education and more – to support care coordination and improve health. As an awardee of DASH CIC-START, NCHIIN worked with partners to add new organizations, sectors, and data streams to ACT.md, their care coordination and alerts notification system. They provided insights about engaging partners to incorporate the system into their workflows to provide more holistic care for patients, especially those with complex health and social needs.
Asset-based community development (ABCD) is a large and growing movement that considers local assets as the primary building blocks of community development, social capital, and health and well-being. Ron Dwyer-Voss, MA, the Owner of Pacific Community Solutions, who also happens to be a long-time friend of podcast host Peter Eckart, joined the show to discuss how ABCD draws on existing strengths of local residents, associations, and institutions to build stronger, healthier, and more sustainable communities. He shared strategies, tools, and examples of how ABCD can be used to engage community residents and support them in understanding and applying their power to improve their neighborhoods.
This episode features two guests from the University of Chicago—Dr. Julia Koschinsky, the Executive Director for the Center for Spatial Data Science, and Dr. Nicole Marwell, an Associate Professor in the School of Social Service Administration. They are leading a project, funded by the Public Health National Center for Innovations (PHNCI), which is analyzing data on geographic access to health and human services to help government officials address gaps and maximize the impact of existing resources. The project will offer a replicable framework and tool for analyzing and improving distributions of public funds for health and human services.
This podcast episode features the work of the Hunterdon County Partnership for Health, a multi-sector coalition that includes over 60 community agencies that share a common interest in improving health in Hunterdon County, NJ. Kim Blanda is a Project Director at Hunterdon Healthcare, Dr. Rose Puelle is a Senior Director of Population Health at Hunterdon Healthcare, and Karen DeMarco is the Director of the Hunterdon County Department of Health. Together, they are working on a project funded by New Jersey Health Initiatives (NJHI) focused on healthier weight as a mechanism for improving community health. The Partnership is addressing obesity-related social determinants of health related to access and transportation, mental health and healthy behaviors.
Padma Thangaraj, MS, PMP, is the Vice President of Information Services & Analytics at All Chicago Making Homelessness History, a nonprofit organization that is working to integrate housing, health, and human services data to coordinate care for Chicago residents that are experiencing housing insecurity or homelessness. As one of the pilot awardees of DASH CIC-START, All Chicago worked to refine their mechanisms for exchanging data between hospitals, health care payers, and the county’s Homeless Management Information System (HMIS). She joined the podcast to share her lessons learned and advice for others working to improve improve residential stability and health outcomes through the integration of HMIS and other data.
Emily Yu, MBA, is Executive Director of the BUILD Health Challenge, an All In partner initiative that supports local collaborations between community-based organizations, health departments, and hospitals/health systems that are working to address important health issues in their communities. She shared examples of innovative multi-sector projects happening across the country and described key learnings, tools, and frameworks for multi-sector, community-driven partnerships working to reduce health disparities caused by system-based or social inequity. To date, BUILD has supported 37 projects in 21 states and Washington, DC.
Podcast host Peter Eckart joined Jeff Jaynes, Executive Director at Restore Hope Ministries, and Aaron Bean, Managing Partner at Asemio, in Tulsa, Oklahoma during a site visit for their DASH CIC-START project, which is applying analytics technology to analyze the overlap between individuals who require basic needs assistance (eg. rent, food, utilities, etc.) and those whose children attend early childhood centers. The project utilizes an innovative technology that allows for analysis of personally identifiable information while preserving clients’ privacy. The results are informing collaborative efforts to knit together programs and services to create a seamless continuum of support for Tulsa’s families.
Joseph Conte, PhD, is the Executive Director of the Staten Island Performing Provider System (SI PPS), an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations. SI PPS is one of 25 groups across the state working on the Delivery System Reform Incentive Payment (DSRIP) program, which aims to fundamentally restructure the health care delivery system by reinvesting in Medicaid to reduce avoidable hospital use. Dr. Conte discussed how the collaboration is working to improve care coordination to better address residents’ social and medical needs.
Dr. Danielle Varda is a “scientist turned start-up founder” who is the CEO of Visible Network Labs, a social enterprise that provides tools, training, and other services to help communities build their capacity to leverage network science to strengthen supportive connections and improve health outcomes. In her work, she leads multidisciplinary teams in tackling complex social systems issues using technology, research, and translation to practice. In this episode, Dr. Varda discusses how to build effective networks and shares strategies and bright spots to guide communities that are building multi-sector collaborations to improve health.