CRISP DC continues to advance whole-person care across the District through its partnership with the DC Department of Health and Findhelp to integrate LinkU, DC Health’s screening, referral, and resource directory platform, into the CRISP DC Health Information Exchange (HIE). Available through both the CRISP DC Portal and InContext, LinkU enables care teams to conduct social needs screenings, search for community resources, and send closed-loop referrals to community-based organizations. Screening and referral information entered into LinkU is shared back to the DC HIE, ensuring care teams have access to timely social needs and care coordination information at the point of care.
A recent collaboration between CRISP DC and the District of Columbia Fire and Emergency Medical Services Department (DC FEMS) highlights the value of this integration and the role social needs data can play in improving outcomes for some of the District’s most vulnerable residents.
Over the past several months, CRISP DC and DC FEMS have worked together to establish a monthly file exchange process that provides DC FEMS with a current list of patients, including any documented social needs Z-codes captured during the previous month. The file also identifies whether a referral has already been initiated through LinkU to address those social needs.
For the DC FEMS Quality Improvement team, this information offers a more complete picture of the challenges many frequently encountered patients face outside of the healthcare setting.
“As a Quality Improvement Analyst on the DC FEMS team, I use this information to identify individuals who are high utilizers of the emergency system and gain a better understanding of the social needs that may be contributing to their repeated use of emergency services. By comparing patients’ social needs data with existing LinkU referrals, I can determine whether additional support or intervention is needed.”
The data supports the work of a multiagency task force focused on helping high utilizers access the resources and services necessary to improve their health and well-being. By identifying patients with unmet social needs and understanding whether they have been connected to available community resources, the team can take a more proactive approach to care coordination and intervention planning.
Through LinkU, organizations across the District can work together to facilitate referrals to community-based organizations that address needs such as housing instability, food insecurity, transportation barriers, and other social determinants of health. This coordinated approach helps ensure patients are connected to the right resources at the right time while providing greater visibility into referral activity and outcomes.
By combining social needs screening data, referral information, and cross-agency collaboration, CRISP DC and DC FEMS are demonstrating how health information exchange can extend beyond clinical care to address the factors that most influence health outcomes. Together, these efforts are helping connect residents to critical community resources, improve patient outcomes, and reduce unnecessary reliance on emergency services.