# Using social and medical data integration to improve primary care and population level chronic disease prevention and management

> **NIH AHRQ R18** · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · 2021 · $654,382

## Abstract

Project Summary/Abstract
As evidence about the impact of social and economic factors on health grows, health care organizations are
increasingly experimenting with strategies to better integrate social and medical services in order to improve
health outcomes. A key element of these whole person care approaches involves identifying patients’ social risk
factors and enabling referrals to relevant internal or external social services, for example to food banks, housing
support services, benefits assistance, or medical-legal partnerships. To facilitate multi-sector social care
coordination in San Diego, California, 2-1-1 San Diego has developed the Community Information Exchange
(CIE), a multi-organization data-sharing system designed to improve care coordination and outcomes for San
Diego’s most vulnerable residents. In primary care encounters, providers can access the CIE to view data about
patients’ social risk factors and service use. The CIE enables providers to adjust treatment at the point of care
to minimize the impacts of social risks on treatment success. The CIE also provides a platform through which
providers can refer patients to non-medical services relevant to identified social risks. The CIE has attracted
national attention as a model for multi-sector care coordination. However, to date, no formal evaluation has
examined how the CIE’s combined health and social data analytics affect clinical care, population health
management, or community health interventions. As part of a CDC grant, in July 2019 2-1-1 San Diego will begin
integrating the CIE platform into the electronic health systems of three Federally Qualified Health Centers
(FQHCs) to facilitate seamless integration of health and social needs data and bi-directional referrals for chronic
disease prevention and management. We propose to leverage this new federally-funded initiative to enhance
the CIE for relevant primary care, population health management, and community agency stakeholders and to
evaluate the impact of the enhanced data on chronic disease primary care and community interventions. First,
we will use a human-centered design process to understand and prioritize barriers and facilitators to using social
risk data for chronic disease-related patient care, population health management, and community health
planning. We will use that information to refine the integrated social and medical risk data dashboards presented
to relevant stakeholders. Following deployment of these dashboards, we will use a mixed-methods design to
evaluate their multi-level impacts on chronic disease-related patient care, population health management, and
community health improvement interventions. We will also identify patient, provider, and organizational factors
that influence the use and impact of the dashboards in these different contexts. This project will be the first to
evaluate the impact of this state-of-the-art social and medical data integration tool on chronic disease
management an...

## Key facts

- **NIH application ID:** 10259697
- **Project number:** 5R18HS027394-03
- **Recipient organization:** UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
- **Principal Investigator:** CAROLINE M FICHTENBERG
- **Activity code:** R18 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2021
- **Award amount:** $654,382
- **Award type:** 5
- **Project period:** 2019-09-30 → 2023-09-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10259697

## Citation

> US National Institutes of Health, RePORTER application 10259697, Using social and medical data integration to improve primary care and population level chronic disease prevention and management (5R18HS027394-03). Retrieved via AI Analytics 2026-05-21 from https://api.ai-analytics.org/grant/nih/10259697. Licensed CC0.

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