Purpose and Learning Objectives: The purpose of this session is to show how healthcare data in rural Mariposa County was leveraged to build community collaboration, design a locally tailored intervention, and monitor and improve a new patient navigation program. Session participants will:

1. Learn how cross-system data sharing can galvanize community collaboration and relationship building
2. Understand how data can inform intervention design to address challenges to healthcare and housing access in rural communities
3. Leave with a blueprint for recreating this community process

Background: In 2021, Mariposa’s Alliance for Community Transformation (Alliance) obtained a grant to improve health outcomes of people experiencing or at risk of homelessness. People in rural areas like Mariposa can face significant barriers to healthcare including a lack of cell phone service and the need for transportation over long distances. To improve health outcomes effectively, Alliance, supported by Homebase, convened cross-system partners to share data and design a data-informed program tailored for rural environments. The program blends patient navigation, transportation services, and referral coordination. Implementation began in September 2021, and data is shared each quarter between the hospital and homeless response systems. Preliminary analysis indicates Alliance is exceeding many of their targets including reducing the frequency of emergency room visits while increasing access to primary care. The impact the program is having on Mariposa County extends far beyond project outcomes and includes an emerging cross-system collaborative that involves the Human Services Department, Probation, County Sheriff’s Office, as well as healthcare partners.

Interactive Session Design: Participants will witness how themes generated by focus groups with lived experience influenced the activities of the model, while the quantitative needs assessment, possible by sharing and matching data across systems, generated interest, demonstrated need, and facilitated cross-system collaboration. Presenters will treat the audience like a system partner while tracking the evolution of this project from needs assessment to program design and evaluation. Audience members will act like focus group participants to provide their perspectives on the design and improvement of the program and learn first-hand how this approach can be successfully used in their own communities.