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Coordinated Whole-Person Care That Addresses Social Determinants of Health
Report

Coordinated Whole-Person Care That Addresses Social Determinants of Health

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This report focuses on five projects funded by Data Across Sectors for Health (DASH) that are developing the data infrastructure to support models of coordinated care across medical and community services. To achieve better health outcomes at a lower cost, clinical and social service providers increasingly need access to information reflecting the social determinants of health, such as employment, housing, and education.

This report summarizes approaches and lessons learned from the five DASH grantees—all of whom have unique target populations, goals, partners, and resources, yet collectively are generating lessons learned with respect to multi-sector data sharing specifically for care coordination. These include Altair Accountable Care Organization (ACO) in Minneapolis, Minnesota; HealthInfoNet in Portland, Maine; the Center for Health Care Services in San Antonio, Texas; the Parkland Center for Clinical Innovation in Dallas, Texas; and the White Earth Nation in NorthCentral Minnesota.

The desired outcome of these models involves system-level changes that are oriented around the whole person, and not exclusively on their health care needs. These models of care require collaboration not just across organizations, but across sectors.

Components of Alignment

Data Icon Data

Author Organization

Data Across Sectors for Health

Publication Date

09.12.2017

Topic Area

Health Care
Mental Health
Public Health
Social Needs
Brief

Intermediary Organizations Are Urgently Needed to Assist in Modernizing Public Health and Addressing the Drivers of Health in the United States

This issue brief describes the different roles intermediaries can play; provides examples of where they have been used in practice; and identifies the risks, benefits, and possible innovations of intermediaries as well as policy approaches that might facilitate their appropriate use.

Publication

“More Than Just Giving Them a Piece of Paper”: Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations

This publication characterizes referrals to community-based organizations by primary care practices, which are increasingly being used by healthcare organizations to invest in social care.

Publication

Revising the Foundational Public Health Services in 2022

This publication provides a framework outlining the unique responsibilities of governmental public health and can be used to explain the vital role of governmental public health in a thriving community; identify capacity and resource gaps; determine the cost for assuring foundational activities; and justify funding needs

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