Connecting patients to needed social services can be challenging for health care providers, who are generally focused on clinical care. Additionally, they are often neither aware of the full range of community services nor have the capacity to refer and follow up with patients. Recognizing that social factors significantly impact health outcomes and spending, 2-1-1 San Diego developed the Community Information Exchange (CIE), a cloud-based platform that enables participating providers to better understand a client’s interactions with health and community services. The CIE includes a social risk assessment tool, provides alerts, and facilitates connections across multiple agencies and providers. The rich client information collected through the CIE is also used to monitor community trends and address local challenges. 2-1-1 San Diego is actively engaging community partners to participate in the CIE in the hopes of improving care coordination and health outcomes for at-risk patients throughout San Diego.
This profile explores how 2-1-1 San Diego is working with social service and health care providers to improve care coordination through an online platform that enables participating providers to better understand a client’s interactions with health and community services.