Collaborative effort to help improve patient outcomes by addressing social determinants

A collaboration between UC San Diego Health and 211 San Diego, a region-wide, non-profit referral service that connects anyone living in San Diego County to community, health, social and disaster services, will help to improve patient outcomes by addressing social determinants.

The region's only academic medical center is the first hospital system in the county to participate in the pilot project, which will improve access to transportation resources for UC San Diego Health patients who have been discharged from the hospital and may have barriers getting to follow-up appointments.

The recently launched effort is made possible through the San Diego Community Information Exchange (CIE), which 211 San Diego spearheads and of which UC San Diego Health is a member.

The CIE works to improve how services, such as transportation, food, legal assistance, and more, are delivered in our region. The services are coordinated through an integrated technology platform that shares information electronically to network partners with the goal of improving the health and well-being of people across San Diego County.

The CIE is a growing network of 132 local partner organizations, working together to break down silos of care across health, social and educational sectors.

The collaborative effort between UC San Diego Health, 211 San Diego/CIE and CIE partners, will allow us to identify the social needs of patients. Then, using innovative technology, we can seamlessly connect our patients to needed resources."

Christopher Longhurst, MD, chief medical officer and chief digital officer at UC San Diego Health

The process works by screening patients to ensure they have access to transportation resources to get to their follow-up appointments. If a patient is found in need of services, they can be connected to more than 410 services offered by the CIE network of providers.

"The overall goal is to provide proactive, patient-centered care and advance equity for patients in our health system," said Donna Beifus, chief administrative officer for care management at UC San Diego Health.

The pilot project will allow for the sharing of challenges and best practices, inform policy decisions and contribute to the ongoing development of the CIE technology platform.

"211 San Diego's mission is to connect people to resources and to partner with our community to transform how people access help," said William York, president and chief executive officer of 211 San Diego.

"We are proud to work with UC San Diego Health to launch this project that is our mission in action. It uses the full strength of our cross-sector CIE network to remove access barriers and get people connected to critical health services."