A new project from HealthShare Exchange, a southeastern Pennsylvania health information exchange, will create a real-time data-sharing and notification platform to identify people 65 and older who have prediabetes or diabetes and have health-related social needs.
The NESSTS (Network for Strengthening Social Services Transitions for Seniors) project was created with support from the Independence Blue Cross Foundation’s Health Equity Institute.
NESSTS facilitates referrals to social service and human services programs and is based on new capabilities created by PA Navigate, a statewide community information network designed to address Pennsylvanians’ health and human service needs by connecting them to community services. PA Navigate is administered by HSX and three other state-certified HIEs and funded by the Pennsylvania Department of Human Resources.
Through this initiative, HSX aims to improve the health of older adults by providing access to timely, coordinated, evidence-based services and benefits for older adults with chronic conditions. “We are pleased to partner with HSX on this important effort to provide solutions that will advance health equity and improve health outcomes for older adults,” IBX Foundation Chair Lorena Marshall-Blake said in a statement.
HSX, in partnership with the IBX Foundation Institute for Health Equity, will convene a task force of Philadelphia-area health centers, benefit program managers, and community-based service providers who can identify gaps and solutions to support older adults and streamline care coordination.
“Diabetes and prediabetes affect all age groups but are more prevalent among older adults. Social factors such as food and housing insecurity and transportation access contribute to the increased burden of disease and are more determinants of health outcomes than the clinical care these individuals receive,” Greg Liptak, vice president of quality improvement and disease management at HSX, said in a statement. “Our connections with health care stakeholders in the Philadelphia region and beyond have uniquely positioned HSX to establish this program, collaborate with local partners, and drive improved health outcomes and health equity in the communities HSX serves. We thank the IBX Foundation Institute for Health Equity for supporting this effort.”
PA Navigate is a collaboration among health information organizations (HIOs) that brings together multiple state agencies, counties, local nonprofit and community organizations, health care organizations, and social service providers. HIOs participating in the project include ClinicalConnect HIE, Central PA Connect HIE, HealthShare Exchange, and Keystone HIE.
Austin, Texas-based findhelp was selected as the PA Navigate platform in September 2023. Existing findhelp clients in Pennsylvania include Penn Medicine, Geisinger, Lehigh Valley Health Network, AmeriHealth Caritas, PA Health and Wellness and Highmark Health.
Through the shared platform, health care providers and social service organizations can track client referrals to better understand and assist clients with their individual needs and help them access services and supports. The system also allows health care providers and service providers to assess an individual’s needs when they visit a doctor’s office or emergency department, receive case management services, or seek help from a community-based organization.
The tool also collects data to help state agencies and their partners better understand the health and human service needs of Pennsylvanians and identify gaps in services and opportunities to improve supports across the state. By considering key social determinants of health, including employment, child care, transportation, food security, access to health care and housing stability, state agencies and partners at the county and local level can help Pennsylvanians achieve better long-term health outcomes.
