Abstract

Advancing community information exchange with physician organizations: Building community-based organization capacity for interoperability

Anna Melville and Mary Margaret Dunneback
Lansing, MI

APHA 2024 Annual Meeting and Expo

Background
The Michigan Department of Health and Human Services (MDHHS) recently analyzed community-based organization (CBO) community information exchange (CIE) needs. While CBOs reported a strong desire for seamless care coordination, 61% of CBOs surveyed currently lack a health care partnership and 75% do not receive funding from health care entities. Physician Organizations (POs), and their affiliated providers, also face challenges completing closed loop referrals to CBOs and ensuring patients receive necessary care to address health-related social needs.

Objective/Purpose
MDHHS and University of Michigan Health-Sparrow aim to strengthen how health care systems and social care organizations collaborate to meet the needs of community members, increasing the capacity CBOs have to participate in CIE.

Methods
As part of a larger primary care multi-disciplinary team, Sparrow Population Health is embedding a Community Dietitian in a local food pantry to create additional safety net support for patients struggling with chronic disease management, compounded by food insecurity.

Results
Findings from the first six months of project implementation include: 1) early biometric data; 2) patient identification/referral metrics; 3) provider/participant feedback; and 4) initial recommendations for programming sustainability.

Discussion/Conclusions
This project builds on statewide health information technology recommendations, including Michigan’s Health IT Commission’s Health IT Roadmap Bridge to Better Health and the Community Information Exchange Task Force Final Report, while also leveraging:

Chronic disease management and prevention Conduct evaluation related to programs, research, and other areas of practice Public health or related organizational policy, standards, or other guidelines Systems thinking models (conceptual and theoretical models), applications related to public health