Next Generation Digital Data Environment to Enable Coordinated, Personalized Care
OVERCOMING INTEROPERABILITY CHALLENGES TO PROVIDE ACTIONABLE INSIGHTS AT THE POINT OF CARE (ISTHMUS AND ISLET)
PROVIDING ACCESS TO CONTEXTUALIZED, NEIGHBORHOOD-BASED SDOH INSIGHTS TO ADVANCE HEALTH EQUITY (ISTHMUS AND CVC)
Knowing more about their populations allows communities to do more. In 2021, we built an SDOH data mart and created the Community Vulnerability Compass (CVC), a novel, web-accessible toolkit with an end-user-tested Power BI visualization dashboard that includes a longitudinal collection of 26 key indicators (curated, normalized, and indexed) that can be used to measure health, resiliency, and economic vibrancy of neighborhoods at the ZIP code, census tract, or block-group levels. Isthmus hosts the SDOH datamart that can be used for many things, including powering the CVC.
As a forerunner of CVC, PCCI created Community Data Insights, an SDOH-based tool that enabled North Texas decisionmakers to evaluate 60+ community-based measures related to health and healthcare access. In constructing the CVC, we thoughtfully expanded this early work by focusing on a limited number of exceptionally meaningful measures, by normalizing measures to facilitate easier cross-measure comparisons, and by indexing measures to better understand relative differences across various need categories. The measures reflect the Healthy People 2020 “place-based” organizing framework of five domains including: economic stability, education, social/community context, health/ healthcare, and neighborhood/built environment. The indices are visualizable at the individual measure level, aggregated sub-index level, and a rolled-up single index score. While other existing tools like the Area Deprivation Index capture community need, they do not drill down to the level of specificity/insight needed to fully inform program/intervention design.
The CVC’s user-friendly interface allows users to view those block groups (neighborhoods) where support could be the most beneficial. Through leveraging Isthmus and the CVC as an easy-to-access SDOH hub, community stakeholders can increase their capacity to use contextualized SDOH insights to make data-informed decisions to improve the health of community residents, including racial and ethnic minority and disadvantaged populations.