By Jolie Ritzo and Jessica Little
Addressing health-related social needs (HRSNs) is crucial to ensure the best health outcomes, improve treatment, and increase care coordination between community and health care settings. Data derived from HRSN screening also informs health care and public health processes such as payment, quality, and population health, and can also influence policies and programs to support the health of communities and individuals.
By leveraging existing data infrastructure from health information exchanges (HIEs) and standardizing how data is coded and exchanged we can transform data derived from HRSN screening into a meaningful resource that benefits patients, providers, and communities, which ultimately supports whole-person health.
Standardizing Data Collection and Exchange
Collecting HRSN screening data within various care settings—social services, community-based organizations, and health care—is the first step toward progress. However, to ensure the best patient experience and lack of duplication, it is important that this data can be shared across settings. This critical aspect lies in standardizing this data for interoperable use and integration into existing processes and tools.
Health-related social needs (HRSNs) refer to individual-level factors, whereas social determinants of health (SDOH) refer to community-level factors, both of which impact an individual’s health and well-being, according to HHS.gov.
Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks, according to health.gov.
Computers cannot interpret responses to HRSN screening questions without a standardized coding system. Data standards can allow for the seamless exchange of electronic codes between unaffiliated providers and disconnected care settings to enable whole-person care. That’s where the Gravity Project ® comes in.
The Gravity Project is a consensus-driven collaborative that leads the development and implementation of SDOH data standards. Gravity supports four clinical activities: screenings, assessment and diagnosis, goal setting, and treatment interventions. Information can be accurately captured and exchanged to advance interoperability by using validated screening tools and standardized coding for HRSN screening data, such as those found in different code sets utilized for clinical activities.
Civitas Networks for Health – A Gravity Implementation Partner
The Gravity Project operates three work streams: terminology, technology, and implementation. Terminology develops languages and codes created through an evidence-based consensus-building process designed to make data publicly available for exchange. The technical workstream addresses how these codes are exchanged, aiming for advancements like Fast Healthcare Interoperability Resources (FHIR) ®. And the implementation workstream advances the adoption of SDOH data standards by meeting communities where they are and providing forums and resources supporting implementation activities.
Civitas Networks for Health (Civitas) is a national nonprofit member and mission-driven organization focused on health data exchange and health improvement; it acts as a bridge between data and doing. As a member and partner of Gravity, Civitas works to support implementation of Gravity data standards in communities throughout states and regions by engaging its members and their partners, connecting them with Gravity experts and resources. Through convening partners, experts, and community members, Civitas supports pilots and peer-to-peer learning forums where implementers can learn from the successes and challenges of others implementing HRSN screenings and standardizing data exchange, allowing members to build upon progress generated by others.
At Civitas’ recent May Collaboratives in Action event, we heard directly from members of the Civitas network leading implementation efforts to embed HRSN screening data in clinical settings within the contexts of their unique state, local, and community perspectives. They shared successes, barriers, and outcomes of their work to provide highly relevant insights that allow others to learn from their journeys.
MyHealth Access Network (MyHealth)
MyHealth Access Network, a nonprofit HIE in Oklahoma, has been addressing SDOH by integrating HRSN screening and referrals into clinical care settings. Having been awarded an Accountable Health Communities (AHC) model grant in 2016, MyHealth embarked on an innovative journey to bridge clinical data with social services, recognizing the fragmented nature of both clinical and HRSN data. The effort led to the creation of the Route 66 Consortium, which united competing communities and established the governance and relationship-building essential for collaboration. Through its role as a state-designated HIE, MyHealth leveraged its data infrastructure to implement a comprehensive social needs screening process, seamlessly integrating HRSN data into clinical workflows and facilitating timely referrals to community resources.
MyHealth developed a workflow that utilized mobile technology to conduct screenings and deliver referral information in real-time, effectively automating the process. This modern approach ensured high screening and response rates while also showing significant reductions in health care costs and provider burden. By May 2024, MyHealth had offered more than 4.5 million screenings, identified and addressed nearly a million social needs, and saved an estimated 250,000 hours of staff effort, roughly equating to $4.5 million in savings. This model showcases the role HIEs can provide in integrating SDOH considerations into clinical care, ultimately improving patient outcomes and enhancing the efficiency of health care delivery.
North Carolina Health Information Exchange Authority (NC HealthConnex) and North Carolina Department of Health and Human Services
North Carolina’s Department of Health and Human Services (NCDHHS) partnered with their state-wide HIE, NC HealthConnex, to improve the exchange of data related to HRSNs within its Medicaid program. NCDHHS aimed to create interoperable data systems that provide necessary, relevant patient data to inform clinical decision-making and provide the best care. By implementing pilots under the 1115 waiver, NCDHHS pioneered a program that allowed community-based organizations to invoice for non-medical interventions and ensure that HRSN screening data was collected. These pilots were geographically limited but aimed to provide valuable insights into the effectiveness of addressing HRSNs through community-based efforts.
To advance similar goals, North Carolina began integrating HRSN screening data from various health systems into NC HealthConnex, creating a unified system that facilitates data sharing. The initial pilot phase involved collaboration with the NCDHHS and selected health care organizations to standardize data collection using LOINC codes and CCD-10 codes. The first phase of this work successfully identified commonalities and variations in screening questions, paving the way for standardized data entry. Moving forward, the state plans to expand the pilot to include primary care practices and Medicaid health plans, aiming to ensure comprehensive data flow from providers’ electronic health records into NC HealthConnex. The goal is to use this data for improved clinical decision-making, policy development, and program evaluation, with a future focus on incorporating referral and intervention data to address identified needs more effectively.
Challenges and the Path Forward
By identifying the needs of individuals and communities, and where there are unmet HRSNs, we can better inform and shape programs and policies that address needs, thereby promoting health equity and overall well-being.
Despite many successes with HRSN screening and standardized data exchange, challenges remain, such as variability in screening tools as well as the associated time and financial costs of standardization. Resources are needed to develop consistent, interoperable rules for validated screening tools and to support the iterative process of building, implementing, learning, and refining these standards. There is also a tremendous need for education and furthering the adoption of existing resources, standards, and tools.
Clarity and appropriate funding for entities responsible for collecting, coding, and exchanging this data are also critical. Different states have varying responsibilities and resources for these tasks, necessitating a collaborative and localized approach to ensure efficiency and effectiveness.
Advancing HRSN screening, data capture and exchange through use of existing HIE infrastructure, and adopted standards is a collaborative and continuous effort that Civitas is supporting through multiple fronts. Civitas is also closely tracking partnerships between CIEs and HIEs, which brings great promise in having more connected and streamlined data across sectors. By utilizing tools, such as those from the Gravity Project, and supporting local implementation, we can improve data exchange, reduce provider and patient burdens, and ultimately enhance health outcomes. This process not only supports whole-person health but also strengthens the foundation for a more equitable and effective health care system.
Jolie Ritzo is Vice President of Strategy and Network Engagement at Civitas Networks for Health. She leads communications and marketing, government relations and advocacy, event strategy, and strategic planning. Jolie previously served as the Director of Partnerships and Programs at the Network for Regional Healthcare Improvement (NRHI). Jolie also serves as President of the Crossroads Board of Directors, a nonprofit organization serving patients and families in Maine with addiction and behavioral health treatment.
Jessica Little is Vice President of Business Development and Programs at Civitas Networks for Health. Jessica oversees Civitas’ portfolio of grant-funded programs and contracts and leads the development of strategic partnerships with funders and program partners. Jessica also serves on the Gravity Project Operating Committee and a variety of other national workgroups aimed at improving health and social care data interoperability.
We encourage you to get in touch with our team at Civitas to hear more about our work, our partners, and answer any questions you might have.
