Leveraging data to support health equity in an integrated delivery and finance system

To accelerate healthcare transformation and advance health equity, scientists in learning health systems (LHSs) require ready access to integrated, comprehensive data that includes information on social determinants of health (SDOH).

We describe how an integrated delivery and finance system leveraged its learning ecosystem to advance health equity through (a) a cross-sector initiative to integrate healthcare and human services data for better meeting clients' holistic needs and (b) a system-level initiative to collect and use patient-reported SDOH data for connecting patients to needed resources.

Through these initiatives, we strengthened our health system's capacity to meet diverse patient needs, address health disparities, and improve health outcomes. By sharing and integrating healthcare and human services data, we identified 281 000 Shared Services Clients and enhanced care management for 100 adult Medicaid/Special Needs Plan members. Over a 1-year period, we screened 9173 (37%) patients across UPMC's Women's Health Services Line and connected over 700 individuals to social services and supports.

Opportunities exist for LHSs to improve, expand, and sustain their innovative data practices. As learnings continue to emerge, LHSs will be well positioned to accelerate healthcare transformation and advance health equity.