Not everyone agrees that health systems should be focusing on social issues that lead to poor health, but there is no doubt that the move to value-based care has made "social determinants of health" the hottest phrase in the sector this year. As the Center for Medicare and Medicaid Innovation (CMMI) and other payers begin to provide funding for housing, food and transportation assistance, pilot projects are springing up across the country to develop partnerships between social service agencies, hospital systems, public health agencies and federally qualified health centers. These multi-sector collaborations are finding that they need a new breed of software platform to bridge previously unconnected caregivers. These community information exchanges (CIEs) are taking many shapes and forms. For instance, in Southern California, 2-1-1 San Diego has built a CIE involving 53 network partners and is starting to use it to formalize referral pathways from physician practices. It includes a social risk assessment tool, provides alerts, and facilitates connections across multiple agencies and providers.
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