Creating a complete care system – Part 3 of the Healthcare Interoperability blog series

  • August 15, 2023

It's widely recognized that people’s life expectancy, health outcomes and quality of life depend on factors beyond traditional healthcare services. Among these factors are social determinants of health (SDOH), and they include a person’s socio-economic status, race, ethnicity, family structure, language and geographical location. The organizations and government agencies attempting to address SDOH are siloed. Health, Housing, Social Welfare, Justice, Education and Transportation organizations each implement programs and solutions based on their specific view of the challenges impacting the population and individuals. Additionally, private groups create and support specific programs such as food pantries, counseling services, secure housing services and justice — resulting in a patchwork of private and government safety nets that function mostly independently of each other. This makes available services disjointed and difficult to navigate.

The gap between these siloed safety net services is where interoperability offers promise. The earlier two posts in this series explored the interoperability journey specific to healthcare. This post explores the potential for interoperability to extend beyond healthcare and encompass an array of social services to develop coordinated support for a multitude of factors impacting a person’s health. The current focus of interoperability enables healthcare environments to share data. The long-range vision of interoperability goes beyond healthcare to include the coordination of social services to enable complete care. This coordinated support depends on easily shared and trusted data.

In a complete care system, social services will network with healthcare services to coordinate support for citizens and improve health outcomes. For example, a homeless shelter would be able to refer a diabetic individual to a primary care clinic, a food panty and health classes. In another example, an individual released from incarceration could have pre-established connections with interim housing and employment services. These are just a few examples of the possibilities in a complete care system. To achieve this, interoperability must continue to evolve.

Addressing challenges to a complete care system

Technical, policy and funding challenges, including data security and interoperability exchanges to non-healthcare services, must be overcome to make complete care work. Here are three challenges that agencies and organizations will need to address:

1. Managing identity — The ability to uniquely identify individuals in a secure manner.
2. Managing consent — The ability to acquire and maintain an individual’s agreement to opt into or out of services coordination and data sharing.
3. Funding, service navigation — The long-term funding of the service navigator function that acts as a coordinator between the need and supply of services. Service navigators will need to be publicly funded with a clear mission to facilitate the coordination of services, thus leveraging the public and private investments already made by numerous organizations.

Accelerator organizations are working on the technical aspect of these challenges that must be resolved to make the future vision of interoperability a reality.

Key components to a complete care system

Two key components needed to connect separate safety nets are business applications and a service navigator. Business applications make it possible to exchange and easily interpret data. The service navigator can help individuals understand the landscape of available services, interpret their needs and connect them to available services. It functions as a hub — turning a collection of separate safety nets into a coordinated tapestry of services. Through the data connections enabled by the service navigator, an individual is supported in a timely, proactive manner, reducing detrimental events both from a social and health perspective.


This approach acts as a framework for addressing the challenges around complete care. The actual implementation of solutions must occur at a local level, since the available support services in Manhattan, NY are likely different than they are in Manhattan, KS. However, the framework provides a pattern for understanding the available services, how to establish connections and navigate them.

Interoperability beyond healthcare

Interoperability between healthcare and social services can provide complete care systems, effectively improving health outcomes. To positively impact a person’s care, the separate services should be coordinated. This won't occur organically and will instead require service navigators and business applications to help connect disparate data. This will likely be an incremental journey, with specific social services gradually being interconnected with the healthcare interoperability ecosystem. As the benefits of these interconnections are realized, the expansion of the network will accelerate, creating complete care systems.

Read the other posts in this series:

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Jeff Strand

As a Senior Business Architect, Jeff interprets changing federal and state legislation and evolving standards into full-featured solutions with an emphasis on user touch points. Jeff has more than 37 years of experience designing, developing, and implementing healthcare processing systems. Recent experience includes implementing the Fast Healthcare Interoperability Resource (FHIR) Application Programming Interface solution in numerous states. Jeff actively participates in Industry Standards Development Organizations and is highly engaged in industry organizations to both contribute to — and learn about — successful 21st century healthcare management.


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