Is social care enhanced by bringing clinical health information into the conversation?

Context: While there is increasing attention to how primary care clinical teams collect and use social risk data (e.g., food, housing), far less is known about how social care providers use clients’ clinical data (e.g., diagnoses, labs) in their care delivery.

Objectives: The San Diego Community Information Exchange (CIE) offers care providers across sectors an opportunity to share social client data (social needs, referrals). We explored the adoption of four new CIE features that integrated clinical data aimed at enhancing social care: (1) addition of clinical data in client profiles, (2) alerts for clients experiencing social risks and diagnoses/medications, (3) panel management dashboard incorporating clinical information, and (4) search filters for community resources based on clinical health information.

Study Design and Analysis: Mixed methods analysis including CIE usage (meta-data) of new features involving clinical data and CIE user qualitative reports from healthcare and social service agencies using rapid qualitative analysis.

Setting or Dataset: 211 San Diego CIE.

Population Studied: 305,048 San Diego resident CIE clients, of which 17.5% had clinical data. 71 CIE users interviewed from 9 healthcare/plans and 18 social service agencies.

Intervention/Instrument: New CIE features integrating clinical health information were released system wide. CIE users were provided synchronous (webinar) and asynchronous (videos, written) training sessions to understand and make use of the new features.

Outcome Measures: View/click rates of clinical information over 12 months; qualitative reports on barriers to use and the perceived impact of integrating clinical data into social care.

Results: Clinical data was viewed in 0.08% of clients with presence of a medical home, health insurance, and health plan most viewed. While qualitative reports pointed to promising opportunities for clinical health information to inform or improve the delivery of social care; awareness and usage of the data was limited. Barriers included lack of added value to the EHR, unsuitability to the workflow of an organization, and the need for more detailed data.

Conclusions: Integrating clinical data into social care delivery had many potential use cases but little application through the available features. Making clinical data more useful to social care practitioners may involve greater implementation support (e.g., training tailored to organization or role) and feature refinements.