Community Information Exchange Micro-Toolkit

Community information exchange that successfully serves people and individuals facilitates better information about what services are available, and, more importantly, how to access those resources in a direct way. In addition, people want to know what information is being collected about their health and social needs, what entities have access to it, and how their information is being utilized, including how it is being changed or removed. 

Successful CIE capabilities would support many technologies that accommodate individuals with differing abilities, diverse languages, and a variety of social needs. Individuals and families should be able to access health and social records, change and/or update health record information, and, if desired, opt-out of data collection and/or exchange. In turn, people will have a system that they can trust and is responsive to their needs and concerns. 

Establishing trustworthy systems is critical because people fear a lack of transparency of data practices, and the potential for improper disclosure of sensitive information can ultimately put people at risk. Apprehension about surveillance might disincentivize people from seeking help. Multiple requests for more or redundant information from different service providers reinforces distrust and is cumbersome to individuals.

Community information exchange must also support healthy and diverse communities. Communities and their leaders need access to information about resources available, to whom they are available, and resource capacities and restrictions. More importantly, communities need access to information about the gaps in resources specific to their communities to understand where there are unmet community needs. 

Successful CIE would provide timely and relevant information to support community-level and culturally competent interventions that improve health outcomes and socioeconomic well-being and reduce inequities while respecting the values and safety of the community. 

Mistrust in communities might yield unequal or nonexistent buy-in, siloing resources, and perpetuating inequities in care and disparities in care and disparities in outcomes. To build trust, CIE must be flexible in supporting the varied needs of diverse communities. Without such commitment to meet diverse communities where they are, and addressing their unique needs, CIE initiatives might result in uneven participation that perpetuates inequities.

Community-based organizations need to know what services are available in their local community and how to access those services in order to share that information with their clients. CBOs vary in degrees of reach, scope, and capacity. The primary focus of local CBOs is to meet people where they are and meet their needs. Some work in partnership with other local CBOs to do this work. In addition, CBOs want access to aggregated, population-level data to demonstrate their program's effectiveness and justify their needs for additional funding. 

A critical capacity for CIE is appropriate levels of funding to train and support CBO staff in processes of collecting, assessing, sending, and using information in new ways that are relevant to their organizational mission. Social service providers want to be able to seamlessly coordinate care for individuals without burdensome worry that the individual will be lost in the system or unable to access the service they're directed to. CBOs also want to be able to convey actionable information about the benefits of individuals' participation.

Government agencies can support local CIE to become more efficient and equitable through funding support, resource allocation, and strategic guidance. To allocate resources, government agencies need information about the availability of services, gaps in services, redundancy of services, as well as demand for services and unmet needs. 

Government agencies also play a key role in alleviating population and organizational concerns about privacy of data. Government agencies should provide clear and ongoing guidance on data-sharing. More importantly, government agencies have an opportunity to effectuate clear guidance by providing information technology (IT) solutions for CBOs to ensure affordability and promote interoperability. 

Government agencies also play a role in equipping CBOs with tools to do this work. In addition to funding and data guidance, government agencies should support on-the-ground partners with standardized trainings for staff, capacity building, guidance on using and sharing data for organizations, and access to guidance on IT solutions.

Health payers- such as health plans, Medicare, and Medicaid- and providers utilize patient data to coordinate with service agencies and target social drivers of health. Health payers and providers want to know what services are offered by CBOs in their local community. At an individual level, they want a real-time understanding of a patient's existing referrals and treatment plans, and a patient's ongoing needs (i.e., from patient records or screening results), risks, and treatment priorities. 

Through effective CIE, health payers and providers could reduce the amount of duplication in the administration of assessments at the client-level and duplication of referrals. Health payers could access aggregated data about the effectiveness of supporting social drivers of health and utilize that data to reimburse social care providers. Finally, health payers and providers could support individuals in accessing coordinated, holistic care.

Michigan 2-1-1 provides connections to services, such as employment support, family support, housing, food, health, public benefits, and more. The MDHHS MI 2-1-1 state office coordinates a network of seven regional contact centers that help people in need of assistance access services. Notably, Michigan 2-1-1 utilizes an application program interface (API) to house its resource directory (with over 30,000 resource referrals) to allow third-party partners access to its database of resources, including MiBridges and the Michigan Hope Portal. 

MI Bridges utilizes the MI 2-1-1 API to provide resource navigation to local and state resources, as well as benefit programs. MI Bridges is an online platform where residents can explore potential eligibility for services, apply for Food Assistance, Medicaid, Child Care Subsidy benefits, apply for state emergency relief, view their case information, or report changes to their MDHHS Specialist. 

In 2022, MI Bridges launched the closed-loop referral pilot program- No Kids Hungry Project- with the Food Bank Council of Michigan and several food banks across the state to improve community partners' ability to support Michiganders facing food insecurity. Through the No Kids Hungry Project, MI Bridges Navigators and referral partners, as well as the client, can initiate requests for services that lower the incidence of food insecurity.

In 2021, Healthify, a private entity working with managed care organizations to address SDOH, initiated a CIE with Blue Cross Blue Shield of Michigan to coordinate nonclinical care for members. Healthify works on closed-loop referral model to increase interoperability among formalized partners to the project.

Genesee County CHIR. In 2019, the Genesee County CHIR began working with providers to promote an SDOH screening tool. The Genesee County CHIR began housing results in a central SDOH repository to aggregate and analyze screening results to identify population-level SDOH needs. In addition, the CHIR implemented a Community Referral Platform (CRP) that provides closed-loop referrals between participating providers the CHIR Hub organization- the Greater Flint Health Coalition- and community/social service agencies. 

Riverstar Community Care Hub- Jackson County CHIR. In Jackson County, the Jackson County CHIR began working with the IT solutions company Riverstar to launch a virtual hub that hosts a SDOH screening tool. The application rolled out in Jackson County utilizes the MI 2-1-1 API to provide resource navigation to individuals in Jackson County. As of January 2020, the Care Hub has provided more than 80,000 SDOH screenings and provided more than 11,000 referrals. 

Northern Michigan CHIR. The NMCHIR serves ten counties in the northwest Lower Peninsula of Michigan. The NMCHIR developed and implemented a web-based, tablet-based screening and referral platform that screens patients for SDOH, refer patients for service navigation, and coordinates care between community services and clinical providers. 

Livingston-Washtenaw CHIR- MI Community Care. In 2015, the Livingston-Washtenaw CHIR launched a free community-wide care coordination program in Livingston and Washtenaw counties. The program offers integration with regional medical providers, including Michigan Medicine and Trinity Health, as well as shared consent forms and protected messaging through an IT platform.

Domain Represented	Name	Organization
Michigan 2-1-1	Bob Kreha	Michigan 2-1-1
Behavioral Health	Joyce Fetrow	Northern Michigan Opioid Response Consortium (NMORC)
Consumer	Patrick McNeal	North Flint Neighborhood Action Council
Consumer	Ammar Alzuad
Health Care	Steve Grulke	Mid-State Health Network
Health Equity	Janée Tyus	Greater Flint Health Coalition
HIT Commission	Renee Smiddy	Michigan Health & Hospital Association
HIT Commission	Marissa Emersole-Wood	Blue Cross Blue Shield of Michigan
Implementing CIE (CHIR)	Kelly Stupple	Washtenaw Health Plan
Implementing CIE (CHIR)	Ed Worthington	Advanced Technology Health Solutions/NMCHIR
MiHIN	Tim Pletcher	Michigan Health Information Network
Payers (Medicaid)	Julia Aronica	Blue Cross Complete
Social Services/CBOs	Dawn Opel	Food Bank Council of Michigan
Social Services/CBOs	Nadeem Siddiqi	Wayne County Metro CAA
Tribal Representative	Tyler LaPlaunt	Sault Ste. Marie Tribe of Chippewa Indians

The task force put forth a set of recommendations with strong consensus alongside a high-level roadmap for implementation. The task force recommendations can be found in the CIE Task Force Final Report (pages 8-10). 

These recommendations include: 

•  Establish core technical capacities necessary to enable interoperability at a statewide scape-including standards for data exchange and identity management services.
• Establish a reliable supply of resource directory information to be provisioned as a public good. 
• Establish a statewide framework for legal agreements that align with existing regulatory frameworks while addressing data collection in contexts that are not otherwise regulate; and establish an ethical framework in the form of a "Bill of Rights" for consumers and communities. 
• Ensure that aggregation of longitudinal data about people and populations can occur with the informed consent of data subjects. 
• Designate and support 'coordinating entities' in the process of facilitating activity among CBOs, government agencies, and healthcare institutions- and ensure that these entities uphold fiduciary responsibilities for the people and organizations that they serve. 
• Establish federated systems of governance through which standards and policies are set statewide, while priorities and implementations can be decided and evaluated locally. 
• Leverage a variety of financing mechanisms to build and sustain these capacities, including the capacity to provide more social services.

2-1-1 San Diego CIE is the first instance of a CIE, holders of the trademark for the term, and conveners of the National CIE Community Network. 

San Diego 2-1-1 defines community information exchange as "a community-led ecosystem comprised of multidisciplinary network partners who use a shared language, resources database, and integrated technology platforms to deliver enhanced community care planning. CIE enables communities to shift from a reactive approach to addressing social needs to an approach that is more proactive, holistic, and person-centered. At the very core of a CIE is the community it serves, and with the community as its compass, a CIE seeks to support antiracism and health equity." 

Find more information about 2-1-1 San Diego CIE here.

Connect4Care is a southeastern Michigan CIE, supported by United Way for Southeastern Michigan (UWSEM). In August 2021, UWSEM and MI 2-1-1 regional contact center initiated a CIE with Henry Ford Health (HFH), Gleaners Community Food Bank for Southeastern Michigan, and the Health Alliance Plan (HAP). Through this CIE, HFH and Gleaners act as initial spokes, connecting through APIs to bidirectionally process and serve patients who have been identified through screenings at HFH facilities as food insecure. 

HFH and UWSEM are also utilizing data to better connect people with basic needs assistance and other support, improve health and social outcomes, and lower costs for health systems. Since this initial use case, the CIE's capabilities have expanded to provide automated connectivity for real-time appointments for tax preparation services, transportation services, transportation assistance through a ride management broker service to Uber and Lyft, and childcare eligibility tests and subsidy application processing and submission to childcare providers across Wayne County. 

 

Find more information about Connect4Care here.

Michigan 211 provides connections to services such as employment, family support, housing, food, health, public benefits, and more. The MDHHS MI 211 staff office coordinate a network of seven regional contact centers that help people in need of assistance access services. Notably, Michigan 211 utilizes an API to house its resource directory (with over 20,000 resource referrals) to allow third-party vendors access to its database of resources, including MiBridges and the Michigan Hope Portal. 

MI 211 is implementing four community information exchange pilots. Learn more about Michigan 211's CIE pilots in the video above.