Our proposal aims to address Area of Interest 1: Referral Management to Address Social Determinants of Health Aligned with Clinical Care.A holistic concept of health, emphasizes a person-centric approach and requires coordinated medical and social services, interoperable systems, and access to and use of appropriate information at each point of care (DeSalvo 2015). We use the theoretical framework of a Learning Health System (Olsen, 2007), defined by the Institute of Medicine in 2007, to envision information sharing that leads to ?continuous cycles of study, feedback and practice change? (Platt, 2020). We will also be guided by the RE-AIM framework, an implementation science tool, to emphasize the reach, effectiveness, adoption, implementation, and maintenance of our solution. We propose to develop and demonstrate a comprehensive and integrated information system to manage (a) social needs identified in clinical settings, (b) bi-directional information exchange between clinical providers and community-based organizations delivering social care, (c) integration in clinical workflow and electronic health records (EHR), and (d) patients? access, consent, and navigation using a mobile digital platform. This ?closed loop? system, we have named FHIRed-SHIP, can be defined as one that helps a clinical provider to identify social needs of a patient, make referral to a social service organization that may address those social needs, and receive information back in their clinical EHR environment from the social service organization, thus closing the information loop of social service referrals in our community. We will demonstrate the implementation and testing of this system in a non- proprietary manner, applying national IT standards for data exchange, in more than one geographical area using (a) Gravity/FHIR application programming interfaces (APIs), (b) nationally available social services referral digital platforms, (c) regional health information ex
changes (HIEs), and (d) secure responsive mobile and web apps. We will use the Gravity Project?s Use Case Package to link our efforts with prior and ongoing national work on defining social determinants of health (SDoH) data standards and leverage prior investments by ONC and local funders in Austin, to deliver an open-source, standards-based, scalable, and implementable referral management solution. We will develop an implementation toolkit for FHIRed-SHIP and pilot it in partnership with two additional regional HIEs in El Paso, Texas and in New Orleans, Louisiana to demonstrate scalability and interoperability of our solution beyond the primary site of implementation. We will rely on data captured on FHIRed-SHIP during this demonstration to assess the potential impact on patient outcomes and social service referrals. This will include data on social needs assessment, social service referrals, and healthcare utilization.The project duration will be two years.