Population and individual health are significantly influenced by social determinants that range from individuals’ knowledge and behaviors to community-level characteristics, resources, and conditions. The expertise and infrastructure to address these multiple and diverse challenges are divided among systems that often fail to work collaboratively because of misalignment between their respective delivery of services, strategy, and financing. To identify strategies for addressing this misalignment by partnering with informatics, public health, and sociology researchers, the principal investigators are examining Federally Qualified Health Centers services to:
- determine the impact of integrated service delivery on health outcomes in a safety-net population;
- determine the impact of community, population, and public health advanced analytics in identifying and linking patients to needed integrated services; and
identify the benefits.