ONC LEAP: Aligning Housing and Health Care Project

Outreach worker with badge crouching at tent and making notes in tablet while talking to refugee

Problem

AllianceChicago developed a care plan to enhance care coordination for individuals experiencing homelessness.

In 2022, AllianceChicago received funding from the Office of the National Coordinator for Health Information Technology (ONC) Leading Edge Acceleration Projects (LEAP) to address the challenges specified in Special Emphases Notice Area 1: Address Health Equity and Social Determinants of Health (SDOH) Through Innovative, Open-Source Technology Tools, and Electronic Health Records (EHRs).

Specifically, the Aligning Housing and Healthcare (AHAH) project proposed to work with a Chicago-based community health center and a homeless service organization to:

Understand and characterize the elements of a comprehensive care plan bridging the domains of need and services across both organizations
Co-design and pilot test a standards-based, open source, interoperable care plan accessible to both organizations and the patients
Conduct a rigorous evaluation of the pilot approach to understand its impact on the organizations and patients and considerations for scaling across additional service domains and institutions

Solution

NORC is leading a comprehensive evaluation of the Aligning Housing and Healthcare (AHAH) project.

AllianceChicago subcontracted with NORC to evaluate the AHAH project, aiming to provide insights into the sociotechnical factors involved in implementing a referral app. To assess both technical feasibility and user experience, NORC conducted a comprehensive evaluation from May 2023 through September 2024. The evaluation focused on three key areas:

Assessing the technical feasibility of leveraging the MCC e-Care Plan and SDOH standards to develop a referral app connecting a community health center with a housing community-based organization
Identifying the challenges and facilitators of implementing the app
Describing participant experiences regarding its design, implementation, use, and utility

This approach showcased NORC’s strengths in innovative evaluation methods for health IT solutions and responsiveness to client needs, ultimately providing actionable insights for scaling the referral app to other settings and enhancing service delivery for providers and patients.

Result

Findings from NORC’s evaluation will guide the future scaling of SDOH-based health IT solutions across diverse service domains and institutions.

The evaluation will summarize the technical feasibility of implementing shared care plans between health care and social service organizations, demonstrating their potential for widespread adoption. Key challenges and facilitators identified during implementation will provide a clear path for overcoming common barriers and capitalizing on facilitators in similar initiatives. The comprehensive report will serve as a valuable resource for policymakers, health IT developers, and health system leaders, offering essential best practices and deployment strategies. This foundational work lays the groundwork for broader adoption of interoperable, SDOH-based health IT solutions, ultimately enhancing service delivery and health outcomes on a larger scale.