The burdens of poor health and the benefits of good health are inequitably distributed due to socioeconomic factors and structural determinants of health. To address these upstream factors, healthcare systems and community-based organizations around the country are increasingly partnering to coordinate medical and social care, and to share data legally and ethically. Cayuga Medical Center (CMC), Cayuga Health Partners (CHP, a local population health management organization with 200+ physicians), and the Human Services Coalition (HSC, the local 2-1-1 information and referral program) are inviting community-based organizations to co-develop an integrated network for care coordination and data sharing in Tompkins County. A robust Community Health Network (CHN) of coordinated healthcare and social services has the potential to drastically improve health outcomes for residents of Tompkins County. However, development of this coordination and data sharing system will need to be iterative and require many avenues for feedback from healthcare staff, CBO staff, and patients/clients to leadership of the CHN.

The purpose of this program evaluation is to document progress toward the project aims; to collect and share rapid and nuanced information about potential barriers perceived by patients, healthcare providers, and community service professionals; and to identify areas for improvement in the CHN.