A new project from Southeast Pennsylvania health information exchange HealthShare Exchange will create a real-time data sharing and notification platform to identify people 65 and older with pre-diabetes or diabetes and health-related social needs.
The project, NESSTS (Network for Enhancing Social Service Transitions for Seniors), was created with support from the Independence Blue Cross Foundation’s Institute for Health Equity.
NESSTS, which will facilitate referrals to social services and social benefits programs, builds on new capabilities created by PA Navigate, a statewide community information network designed to address health and social care needs for Pennsylvanians by connecting them to community services. PA Navigate is managed by HSX and three other state-certified HIEs and is funded by the PA Department of Human Services.
Through this initiative, HSX aims to improve the health of seniors with these chronic conditions by providing them with timely and coordinated access to evidence-based services and benefits.“We are excited to work with HSX on this important initiative to enable solutions for greater health equity and improve health outcomes for seniors,” said Lorina Marshall-Blake, president of the IBX Foundation, in a statement.
Working in collaboration with the IBX Foundation Institute for Health Equity, HSX will convene a task force of Philadelphia-area health centers, benefits program managers and community-based service providers that support seniors and can identify gaps and solutions to streamline care coordination.
“While diabetes and pre-diabetes affect people of all ages, they are more prevalent in seniors. Social factors, such as food and housing insecurity or transportation access, contribute to higher disease burden and are more determinant of health outcomes than the clinical care these individuals receive,” said Greg Liptak, vice president, quality improvement and disease management at HSX, in a statement. “Our connections to healthcare stakeholders in the greater Philadelphia region and beyond uniquely position HSX to establish this program, collaborate with our local partners and help drive better health outcomes and health equity for the community that HSX serves. We’re grateful to the IBX Foundation Institute for Health Equity for their support of this initiative.”
PA Navigate is a collaborative effort among health information organizations (HIOs) and brings together multiple state agencies, counties, local nonprofits and community organizations, healthcare entities, and social services providers. HIOs participating in the project include ClinicalConnect HIE, Central PA Connect HIE, HealthShare Exchange, and the Keystone HIE.
In September 2023, Austin, Texas-based findhelp was chosen as the PA Navigate platform. Existing findhelp customers in Pennsylvania include Penn Medicine, Geisinger, Lehigh Valley Health Network, AmeriHealth Caritas, PA Health and Wellness, and Highmark Health.
Through a shared platform, healthcare providers and social services organizations can track client referrals and better understand and assist with a client’s individual needs, helping them access services and supports. The system will also allow healthcare and service providers to assess an individual’s needs during a physician’s office or emergency department visit, when receiving case management services, or seeking assistance from a community-based organization.
The tool also will gather data that can help the Commonwealth and its partners better understand health and social services needs of Pennsylvanians and identify service gaps or opportunities for better support across the state. By looking at critical social determinants of health, including employment, child care, transportation, food security, access to healthcare, and housing stability, Commonwealth agencies and partners at the county and local level can help Pennsylvanians achieve better long-term health outcomes.
