A new report from the National Academies of Sciences, Engineering, and Medicine proposes that social determinants are driving many health outcomes and that addressing issues like transportation and housing should be a priority for policymakers seeking to improve overall health. The report, “Integrating Social Care into the Delivery of Health,” showcases work being done in Oklahoma by the “Route 66 Consortium,” led by MyHealth Access Network in partnership with the Oklahoma City-County Health Department and the Tulsa Health Department, which seeks to unite health care and social service organizations in a coordinated effort to address social issues impacting the overall health of Oklahomans.

The Route 66 Consortium is a partnership between MyHealth Access Network, many health systems throughout the state, community service organization and the Tulsa and Oklahoma City-County health departments for the Accountable Health Communities project. Patients at participating health systems are screened at arrival in five key areas that contribute to overall poor health outcomes: housing insecurity and quality, food insecurity, utility assistance, interpersonal violence, and transportation needs. High-risk beneficiaries are connected with AHC community health workers, called “navigators,” who then work with patients and their families to identify social needs and help connect them to existing community resource organizations such as foodbanks, shelters, utility assistance programs and reduced-fair ride services. This system of screening and providing resources relies on the ability to securely communicate with patients and share data between systems in real-time, a process developed and delivered by MyHealth, which provides the technological infrastructure for the Route 66 Coalition.

The authors of the new report emphasize that the success of any program working to address social needs will hinge on the ability of health care and social service organizations to share resources and information. They write: “The ultimate goal is to harmonize activity, services, and funding for these resources in order to maximize effectiveness. An example of an organization involved in such an alignment approach [is the] Route 66 Consortium … Because these alignment efforts extend beyond the support of individuals, community-level data … [is] needed to connect people with social needs with the appropriate resources. Such work will require the sharing of health and social care information across a wide array of community partners and with the consumer.” This is the type of work being done by MyHealth Access and partners through the Route 66 Consortium Accountable Health Communities project.

At the center of these efforts is technology, which provides new tools for both medical professionals and the social service sector.  “By leveraging data and technology, the healthcare sector and its social care partners have an opportunity to improve the efficiency, effectiveness, and sustainability of efforts that address health-related social needs as a regular component of healthcare delivery,” the report’s authors write. MyHealth Access Network is proud to be leading this groundbreaking program in Oklahoma focusing on bringing healthcare and social services organizations together by providing the digital infrastructure to support this work surrounding social determinates. As always, MyHealth is committed to using secure health information data to improve health outcomes.

The Route 66 Consortium works with patients and their families to identify social needs and help connect them to existing community resources.