Healthcare Innovation Awards: CommunityRX System: Linking Patients and Community-Based Service

Publication Year: 2019
Patient Need Addressed: Care Coordination/Management
Population Focus: Medicaid beneficiaries, Vulnerable/disadvantaged
Demographic Group: Adult, Child
Intervention Type: Partnership, Staff design and care management, Technology/innovation
Type of Literature: Grey

The University of Chicago Urban Health Initiative in partnership with Chicago Health Information Technology Regional Extension Center (CHITREC) and the Alliance of Chicago Community Health Services received an award to develop the CommunityRx system, a continuously updated electronic database of community health resources that will be linked to the Electronic Health Records of local safety net providers. In real time, the system will process patient data and print out a “HealtheRx” for the patient, including referrals to community resources relevant to the patient’s condition and status. Aggregated data on patient diagnoses and referrals will be used to generate CommunityRx reports for community-based service providers to use to inform programming. The program will serve over 200,000 patients on the South Side of Chicago most of whom are Medicare, Medicaid and CHIP beneficiaries. The CommunityRx system will train and create new jobs for a combined total of over 200 individuals from this high-poverty, diverse community. This includes high school youth who will collect data on community health resources as part of the Urban Health Initiative’s MAPSCorps program. It will also include the creation of a new type of health worker, Community Health Information Experts (CHIEs), who will assist patients in using the HealtheRx and engage community-based service providers in meaningful use of the CommunityRx reports. The CommunityRx builds on infrastructure supported by ARRA funding from the National Institute on Aging. Anticipated outcomes include better population health, better use of appropriate services, increased compliance with care, and fewer avoidable visits to the emergency room with estimated savings of approximately $6.4 million.

Insights Results