As much as 90% of our overall health is determined not by clinical factors, but by social, behavioral, and environmental factors – also known as social determinants of health (SDoH) – such as access to food, transportation, housing, and employment. Clinicians and other providers could benefit greatly from understanding the social, behavioral, and environmental contexts in which their patients live and work. And social service organizations could better serve their clients if referrals were streamlined and SDoH information was shared and accessible across the provider community.
In the Social and Health Information Platform (SHIP) project, we are creating a data platform that will sit “on top” of providers’ existing IT systems and link patients’ clinical and non-clinical data, combining that complex information and turning it into actionable alerts, dashboards, and visualizations. The SHIP platform will be co-created with the people it is designed for – clinicians, social service providers, and residents of the Austin community.
SHIP will make this clinical and social data available to all care team members and stakeholders (with patient consent), creating a unified longitudinal client record, facilitating smoother referrals to social services, and ensuring that the status and outcomes of referrals are sent back to clinical providers (i.e. “closing the loop”). In addition to improving service coordination and quality of care at the individual level, SHIP will also aggregate clinical and SDoH data at the community level to provide a platform for local population health reporting – an integral step in identifying service needs and gaps in our community and allocating funding and resources where they are most needed.
This research is funded by the generous funding from the Michael and Susan Dell Foundation.