Center for Health Equity

Project Details:

The Health Equity Collective is dedicated to addressing the social, economic, and environmental factors that account for up to 80% of an individual’s health. In the U.S., where more is spent on medical care than on social care, health outcomes remain poor due to systemic barriers and a lack of integrated healthcare systems. We aim to create a sustainable, data-driven system that promotes health equity by connecting healthcare and social services. Our initial focus is on reducing food insecurity in the Greater Houston region by5% by 2025, which will improve health outcomes related to diabetes, obesity, mental health, and COVID-19. We are building a comprehensive data-sharing ecosystem to understand and address the social determinants of health (SDOH).This approach will be expanded to other SDOH areas, ensuring a holistic improvement in community health. With the CHE serving as the backbone organization, we are thrilled to provide staffing and support for communication of the HEC’s progress. This includes website development, event promotion, writing articles, white papers, and one pages, brand support and graphic design.

Key initiatives include:

1.) Enhancing the capacity of Community Health Workers 

Starting fall 2022 in partnership with the City of Houston Health Department, the HEC launched a comprehensive effort to strengthen the Community Health Worker (CHW) workforce in the Greater Houston Region using a systems approach. Our newsletter highlights key achievements of this initiative.  

We also created a website with resources and training opportunities for CHWS.  

 2.)  Creating a Community Information Exchange or Closed-Loop Referral  

A CLR, also called a Community Information Exchange (CIE), creates a bidirectional flow between healthcare and community-based organizations to track referrals.  

In January 2023, ten health care and social service organizations in Greater Houston started a project to improve how they refer patients to each other. They used advanced technology to connect health information systems, which helps track over 18 million patients, and created a system to ensure that patients receive the social services they need. 

4 Pillars:  

1. Collaboration: They set up a way for organizations to work together and make decisions, building trust and transparency. 

1. Technology Connections: They linked existing systems to make it easy for organizations to refer patients and track what happens after the referral. 

1. Resource Directories: They included local resource directories in their technology to make sure patients can access quality services. 

1. Evaluation: They will assess how well this system improves health equity, efficiency, and reduces costs. 

The goal of this project is to enhance coordination between health care and social services, evaluate how effective the referrals are, and support future research on social determinants of health (SDOH) in a fair and effective way. 

 Project Contact: Heidi Hagen McPherson, MPH

Project Team

Shreela Sharma, PhD, RDN, LD

Co-Lead, Health Equity Collective

Director, Center for Health Equity

Professor and Vice Chair, Department of Epidemiology

[email protected]

Heidi Hagen McPherson, MPH

Co-Lead, Health Equity Collective

[email protected]

Jemima John, PhD, MPH

Assistant Professor Department of Epidemiology

[email protected]

Rosalia Guerrero

Manager, Community Health Workers 

[email protected]

Wesley Gibson, MPH

Research Coordinator, Center for Health Equity

[email protected]

Sisan Tennyson, MPH

Research Coordinator, Department of Epidemiology

[email protected]

Publications:

John, J. C., Gonzalez, J., Chan, S. G., McPherson, H., Aiyer, J. N., Galvan, E., Browning, N., & Sharma, S. V. (2023). A coalition-driven examination of organization capacity to address food insecurity in Greater Houston: a qualitative research study. Frontiers in Public Health 11, 1167100.

John, J. C., Kaleemullah, T., McPherson, H., Mahata, K., Morrow, R. B., Bujnowski, D., Johnston, A., Danho, M., Siddiqui, N., Walsh, M. T., Haley, S. A., Sirajuddin, A. M., Schauer, T., Wu, M. J., Rechis, R., Galvan, E., Correa, N., Browning, N., Ganelin, D., Gonzalez, J., … Sharma, S. V. (2021). Building and Advancing Coalition Capacity to Promote Health Equity: Insights from the Health Equity Collective's Approach to Addressing Social Determinants of Health. Health Equity, 5(1), 872–878.

Sharma, S. V., McPherson, H., Sandoval, M., Goodman, D., Paret, C., Mahata, K., Husain, J., Gallagher, J., & Boerwinkle, E. (2024). Design and framework of a technology-based closed-loop referral project for care coordination of social determinants of health. Population Health Management.

News Articles: 

Closed Loop Referral demonstration project: building the technology to improve health outcomes

Leading the Way: CHW Early Adopter Learning Cohort 

Strengthening Community Health Worker workforce in Greater Houston

The Health Equity Collective celebrates 5 years of collective impact

Sharma, McPherson, John, and Guerrero presented at Healthier Texas Summit

McPherson awarded NBHP Community Program Champion for the Harris County Pathways Community HUB