Coordinated whole-person care that addresses social determinants of health: DASH communities generate lessons learned about the required data infrastructure and systems

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—as they have a profound impact on health. In 2015, the Robert Wood Johnson Foundation (RWJF) launched Data Across Sectors for Health (DASH), an initiative to align health care, public health, and other sectors to systematically compile, share, and use data for understanding factors that influence health and developing more effective interventions and policies. DASH awarded ten $200,000 grants to communities across the country to use data-informed approaches to address a range of population health and care coordination challenges.

While there are many ways communities can integrate data to improve health, this brief focuses on five DASH-funded projects that are developing the data infrastructure to support models of coordinated care across medical and community services. These include: Altair Accountable Care Organization (ACO) in Minneapolis, MN; HealthInfoNet in Portland, ME; the Center for Health Care Services (CHCS) in San Antonio, TX; the Parkland Center for Clinical Innovation (PCCI) in Dallas, TX; and the White Earth Nation in NorthCentral Minnesota.