Kimber finally left when her husband tried to choke her and said he wished  she was dead.
The marriage started out well, she tells  her women’s shelter counselor, until he started drinking too much. Then the violence began. Today, she’s the mother of two young girls, without a job, a car, a home, personal security, family or social support. 

Fortunately for Kimber, the shelter  she found is part of Boulder County Department of Housing and Human Services’ integrated system of social services providers. She will only have to tell her story once, and the shelter worker will assess all her health needs—social, emotional, physical and financial. She’ll help Kimber sign up for Medicaid coverage for the family, apply for food and housing assistance, job training, mental health counseling, transportation and shelter. In Boulder County, they call this a no-wrongdoor approach to serving clients.

What’s more, Kimber’s assessment data will be entered, real-time, into an integrated data warehouse. Dozens of organizations— serving social, mental and physical health needs—will be able to find her in this system. They can add notes to the record as services are provided, or as case managers create a care plan—with Kimber—to help her achieve her goals. And Kimber can also access her information through a client portal—so she can track her own progress.

Connecting health care providers through an electronic records platform is not a new concept; about 99 percent of U.S. hospitals had partially or completely implemented electronic health records in 2016, with many allowing at least limited access  by contracted physician offices and  group practices.1 Less pervasive, but  not uncommon, are health information exchanges (HIEs) that allow health care providers and patients to access and securely share a patient’s medical information electronically. 

An S-HIE brings together the many community-based organizations that meet client needs for the social determinants of health—such as housing, food, safety, transportation and employment—and links them with organizations that provide mental, behavioral and physical health services as well. It’s a bridge connecting health care delivery and the real-life circumstances in which people live, work and play—the social determinants of health that contribute to our nation’s high health costs.