The Call for Outcomes
In 2024, Gravity conducted a set of initiatives: the Social Care Voice Co-design project and the Gravity member-led Payment and Reporting and Outcomes discoveries, all of which highlighted the need to develop additional data standards for the documentation and exchange of outcomes from social interventions. The ask was to move beyond our terminology and SDOH Clinical Care Implementation Guide (SDOH CC IG)ās referral-to-social-service use case toward documenting and exchanging the end result for the patient.
āReferrals are just the beginningā was the charge. There were existing methods for documenting outcomes (e.g., IG statuses and changes in severity by instrument or condition). However, concepts for documenting and exchanging patient enrollment in core social and community-based services were a crucial missing step. Enrollment status is not itself a measure of improved health or well-being. It provides an important link between a referral and subsequent service delivery and outcomes. What we know is that it is not referring to a WIC (Supplemental Nutrition Program for Women, Infants, and Children) agency, but enrollment in the WIC program, which offers long-term health benefits for patients and families. It is not just referring to a local public or tribal housing authority, but enrollment in longitudinal housing programs that stabilize family economies and well-being. Treating established diabetes is, of course, important, but preventing and monitoring its development through patient enrollment in evidence-based community programming is ideal. Documenting program enrollment has always been a fundamental part of care coordination and care planning. In early assessments, Gravity clearly saw program status documented in internal coded standards in national electronic health records and community referral platforms. But until this year, there was no way to represent this critical information in national, interoperable data standards. Members identified this as a roadmap priority within a set of enhancements toward reporting and outcomes in 2025.
āA health program: A structured series of actions and strategies designed to maintain, promote, or improve the health of individuals and/or communitiesā (~ CDC)
Standards for Program Documentation and Exchange
To support this goal, the terminology team first audited each intervention concept since Gravityās inception in 2019 for core national programs and definitions. The team then submitted program concepts to SNOMED CT for a first set of 54 priority national programs. These concepts were published in the March 2026 SNOMED CT release. The team is now the ongoing steward of a program value set in the Value Set Authority Center (VSAC). In tandem, the technical workstream created standards for documenting and exchanging observations about program enrollment, leveraging the program terms and value sets in STU3 of the SDOH CC IG. Together, these developments enable care teams to identify many core federal, tribal, community-based, and social service programs using standardized codes and exchange individualsā enrollment status using FHIR, supporting better care coordination.
A Deeper Dive on Current Program Concepts
A selection of program concepts in the first set of programs, includes:
- Housing ā All core U.S. Department of Housing and Urban Development (HUD), tribal, and territorial homelessness, rental assistance, and public housing programs. Plus, Federal Housing Administration (FHA) and community land trust homeownership programs.
- Food & Nutrition ā Evidence-based food as medicine programs, all major United States Department of Agriculture (USDA) and Older Americans Act (OAA) nutrition programs.
- Energy & Utility needs ā Administration for Children and Families (ACF) energy and water assistance programs and local water shutoff protection programs.
- Income & Employment ā Income assistance, unemployment, job center, and vocational rehabilitation programs.
- Transportation & Health ā Non-Emergency Medical Transportation (NEMT) and prescription medication assistance.
- Education & Early Childhood āHead Start
Programs Pending in Future Releases: Community-based Prevention and Treatment
After the first priority submission, the Gravity team has continued to work with SNOMED CT on supporting evidence-based community-delivered program concepts, such as concepts for the Centers for Disease Control and Prevention National Diabetes Prevention Lifestyle Change Program and Arthritis-appropriate, evidence-based physical activity and self-management programs, given our mission to support community providers in evidence-based service provision. These will be included in future SNOMED CT releases and VSAC value set updates.
Toward Supporting Program Exchange with Core Data for Interoperability
One of Gravityās greatest strengths is its capacity to leverage its diverse stakeholders to assess the impact of standards long before they are built. Now that the data standards exist and given the critical nature of understanding and sharing program enrollment toward patient care and patient care coordination, Gravity submitted a United States Core Data for Interoperability (USCDI) request for both Programs generally and Social Determinants of Health Programs this summer. The program concepts that Gravity curates are just a small fraction of the known programs critical to monitor and assess over time toward patient health and well-being. This submission serves as a first step toward addressing a critical gap in the comprehensive, interoperable understanding of a patientās holistic therapeutic story.
Access the Value Set and Get Involved
The updated value set is available now in the NLM Value Set Authority Center (VSAC) ā search by OID 2.16.840.1.113762.1.4.1247.312. To learn more about the program enhancement effort or get involved in the Gravity Project’s terminology work, visit thegravityproject.net.
