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Breaking Down Barriers: How the University of Colorado Hospital is Improving Social Determinants of Health Data Sharing

September 1, 2023

In an era where health care is evolving to embrace a more holistic approach, the University of Colorado Hospital has emerged as a trailblazer in bridging the gap between medical care and social needs. With support from Civitas Networks for Health, a national network of multistakeholder, data-driven collaboratives, and The Gravity Project, a multi-stakeholder collaborative developing data standards for social needs data interoperability, the hospital is making strides to improve social determinants of health (SDOH) data sharing within its walls, ultimately breaking down barriers for patients to receive the social care they need and deserve. This collaborative effort reflects a comprehensive commitment to holistic patient well-being and is already yielding promising results.

Spearheaded by Tehreem Rehman, MD, MPH, former Emergency Physician for the University of Colorado Hospital and now practices at Mount Sinai Hospital, this project sets out to revamp the way SDOH data is collected, shared, and acted upon within the University of Colorado Hospital. With immense support from Civitas and the Gravity Project – providing technical assistance and tools such as social risk terminology value sets and an implementation guide – the initiative focuses on enhancing how social needs are screened, particularly in the emergency department (ED) setting. The overarching goal is to create a more efficient, effective, and equitable process for identifying and addressing patients’ social care needs so health care professionals can integrate social workers faster and earlier.

Empowering Frontline Caregivers

One of the cornerstone principles driving this project is the empowerment of frontline caregivers, especially nurses. Recognizing that nurses often establish more substantial connections with patients, the initiative aims to tap into their insights and observations. By equipping nurses with the tools and autonomy to share valuable patient information with providers, social workers, and navigators, the project seeks to ensure a more comprehensive and patient-centered care approach. This paradigm shift in care coordination underscores the hospital’s commitment to equitable, high-quality, value-based care delivery for every person who walks through their doors.

To achieve its ambitious goals, the University of Colorado Hospital has taken a multi-pronged approach. The project team has scrutinized existing workflows, identifying areas for improvement in screening and referrals and, in turn, streamlined flowsheets that integrate structured data with frontline insights. By embracing this approach, the hospital has paved the way for more efficient data sharing and documentation. Moreover, the hospital is collaborating closely with the Gravity Project to establish standardized terminology for key SDOH categories like food, housing, and utilities. This alignment ensures that data collection remains consistent and meaningful across various patient interactions, and can be replicated elsewhere.

Why Cross-Hospital Collaboration and Person-Centric Design Are Key to Success

Central to the success of this initiative is the unwavering commitment to early and frequent engagement of all team members, from administrative staff to social workers, nurses, residents, faculty, and executive leaders. The project exemplifies the importance of inclusive collaboration, valuing the diverse perspectives and expertise each team member brings to the table. By involving stakeholders from the outset and nurturing a culture of shared responsibility, the hospital has laid the groundwork for sustainable and impactful change.

In the digital age, the importance of user-friendly tools cannot be overstated. The University of Colorado Hospital recognizes that effective SDOH data sharing hinges on user-centric design. By ensuring that the system caters to the needs and preferences of providers, instead of hindering them with yet another platform to work in, the hospital is promoting seamless adoption and utilization within their existing systems. The project acknowledges the significance of patient engagement, aiming to make the tool accessible and easily updatable to reflect evolving patient circumstances and promote transparency.

Looking Ahead: What’s Next for the University of Colorado Hospital?

As the pilot project gains momentum, the University of Colorado Hospital remains committed to its vision of equitable care delivery for its patients. While it’s too early to share definitive numbers, the hospital is closely monitoring screening rates and resource referrals to measure success and opportunities for the initiative over time. The ultimate aim is to double both metrics, providing a more comprehensive safety net for patients’ social care needs. By aligning with the Gravity Project’s national consensus-based SDOH data standards and harnessing the power of collaborative innovation, the University of Colorado Hospital is setting a transformative example for health care institutions nationwide.

The University of Colorado Hospital, through the Gravity Pilot, represents a pioneering initiative that is tirelessly working to enhance SDOH data sharing and dismantle barriers to social care in an interoperable and scalable way. This initiative exemplifies the value of interdisciplinary collaboration, patient-centered design, and a steadfast commitment to equitable care delivery. As the project continues to evolve and its impact becomes more evident, it stands as a testament to the transformative potential of addressing social determinants of health within the health care landscape.

With generous support from the Robert Wood Johnson Foundation (RWJF), Civitas Networks for Health has partnered with the Gravity Project® leadership, Health Level Seven® (HL7®), and various Civitas members to facilitate the dissemination and implementation of Gravity Project standards through Q4 2023. Our efforts involve engaging with national, regional, and local community partners to gain insights from and provide support for the Gravity pilot’s work stream. 

Support for this project was provided by RWJF. The views expressed here do not necessarily reflect the views of the Foundation.