Sharing Social Needs Data Across Sectors: Lessons from the Centers for Medicare and Medicaid Services Innovation Center’s Accountable Health Communities Model

Health-related social needs (HRSNs), like unstable housing, inability to afford utilities, food insecurity, unreliable transportation, and lack of personal safety, profoundly affect people’s health and well-being. Between 2017 and 2022, awardees of the Accountable Health Communities Model (AHC) addressed the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services. Using and sharing HRSN data between clinical and community partners was a critical component of these efforts. This article shares findings from focus groups and interviews with 19 AHC awardees and seven of their partners. It explores the following:

1. Whether sharing HRSN data with clinical partners informed clinical care
2. Successes and challenges related to sharing data with community-based organizations (CBOs) and clinical partners
3. How awardees collected and used HRSN data to advance health equity

Half of awardees interviewed documented HRSNs in electronic health records and shared aggregated HRSN data with CBOs. HRSN data enabled some clinicians to adjust patient care, although most were uncertain about how to do so. Participants described how sharing HRSN data with communities informs program and funding priorities to improve equity. However, CBOs noted that they had limited incentive to participate in data-sharing platforms. Our work highlights opportunities to provide guidance to clinicians on how to use HRSN screening results in care, standardize HRSN screening results in electronic health records, and co-create data-sharing initiatives with CBOs and patients to ensure meaningful participation.