Social Needs Analytics Platform (SoNA)
SoNA aims to integrate health-related social needs and community health data that are essential for strengthening CommonSpirit’s role in improving overall health and wellbeing of our communities, accelerating racial justice and health equity, and sustaining our model of equitable, person-centered integrated care.
- Assess all Community Health data (including CCN data) and acquire, normalize, and integrate into data lake
- Match to All Payors Claims Database (AVS) and EMR clinical and demographics data to inform needs and opportunities for the care continuum and to understand the holistic cost of care.*
- Create dashboards to help data visualization
- Create pathways to access data to run analyses
- Risk Stratify to assist with CCN and other Community Health initiatives
The CCN financial model was developed to ensure that large systems weren’t issuing community solutions. This model positions community partners and anchor organizations to do and manage the work when creating coordinated networks of care, shifting power back into communities. Social determinants of health have complex, structural causes that require multi-sector partnership. CommonSpirit Health views the CCN as a public utility that allows sustainable investment from varying stakeholders towards addressing SDoH while centering care and ownership in communities.
The model is designed to be sustainable so that a CCN may endure even if a participating organization or funding partner leaves the network. Sustainability is built into the model through the evaluation and use of data and analytics; capacity building to ensure community organizations continue to have the bandwidth and ability to continue providing services; workforce development to serve the most vulnerable populations and creating pipelines for permanent jobs; advocacy and policy to ensure long-term policy changes for sustainable funding of social/economic resources as part of healthcare and to break down barriers between medical and social care; improving equity and reducing health disparities through deep community collaboration and through targeted interventions and outreach; and innovative payment models to financially support robust social care across the continuum.
Community costs associated with operating the CCN are covered through a community bank model rather than reliance on grants. The community bank allows for all health system providers, payers, government agencies, clinics and medical groups, and other stakeholders to collectively fund the development and build of a community network. This approach ensures every stakeholder has ownership and accountability to the initiative and can promote the growth of the work. Furthermore, it prevents the initiative from collapsing if one organization changes priorities or halts funding for the work. The community bank requires a minimum three year commitment from each co-funder.
Contributors to the community bank are considered funding partners, which can include any stakeholder who benefits from the CCNs impact. The CCN will also adopt social financial payment models to help fund increased community capacity for community-based organizations (CBOs). By tracking outcomes of the electronic referrals, funding partners and beneficiaries will have the ability to track the benefits their members receive from the network and can specifically create reimbursement models for specific services that help their members most.
It is important to note that the Connected Community Network is a community solution, not one owned by CommonSpirit Health. CommonSpirit is an equal partner with others contributing to the community network. Therefore, the work is anchored in the community with local organizations and institutions leading the initiative as conveners. We partner amongst and across disciplines, service areas, and populations served. We do not make assumptions regarding current practices, nor do we pretend to know what is best without first understanding others’ perspectives. Collaborative partners include hospitals, payers, government agencies, faith-based organizations, schools, clinics, community based organizations and other national organizations.
Read more about the community bank model here.
Rooted in Equity
Health disparities are shaped by determinants of health such as social factors, environmental factors, behaviors, etc, and achieving health equity demands cross-sector engagement. Reaching health equity cannot be done in silo but as a community wide effort. The CCN’s foundation is designed for achieving health equity through its diversity of partners, shared coinvestment, and centering the initiative in the communities themselves. The CCNs tenets apply an equity lens to foster community engagement and ownership, trust, and accountability. Community voice is critical for the network’s success and for the iterative learning process for how the CCN is designed and scaled. Community partners are engaged at the initiative’s outset; not as an afterthought. A set of principles help guide the development of the network and expectations of all stakeholders involved.
Moreover, with the consent of individuals, the network permits the collection of social data in settings they feel more comfortable disclosing them. This allows measurement of and interventions towards health disparities. Currently, CommonSpirit’s CCNs predominantly serve areas with a Community Needs Index (CNI)* score of 5.0 with 27% of individuals identified as Latinx.
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