Improving Health Outcomes for Patient Groups

HSX population health programs are aimed at improving care for groups with unique needs. HSX members can activate data for focused populations based on clinical conditions, patient demographics or gaps in care.

Connecting PA Seniors with Social Service Benefits

This project is funded by the PA Department of Aging in collaboration with Benefits Data Trust (BDT) and HSX. With the cooperation of selected healthcare providers, HSX identifies older adults who may qualify for PACE (The state’s low-cost drug coverage program) and refers them for potential outreach by BDT. Those who call into the PACE Screening Center are screened by BDT for PACE and 18 other benefit programs (e.g., SNAP, LIHEAP, low-income housing assistance) and applications are submitted on their behalf.

Recent Results 

As of October 2022, this program had identified 738 households eligible for benefits, totaling $1.2 million in annual benefits for Pennsylvania seniors from four (4) health systems in our region: Temple Health, Jefferson Health, Penn Medicine and Einstein Health.

How Do HSX Members Benefit? 

  • Benefits to providers/payers include improved medication adherence, fewer hospitalizations and readmissions, shorter length of stay, and lower costs for uncompensated care. 
  • Benefits for older adults include improved access to resources that promote their health, security and independence.
  • Ongoing security, as these benefits are eligible annually

 Other Population Health Projects

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 Know Diabetes by Heart  

HSX partnered with the American Diabetes Association (ADA) to support Know Diabetes by Heart as a facilitator for a quality improvement collaborative among several of the region’s health systems and to provide regional population health data on patients with diabetes, cardiovascular disease and kidney disease. Learn more about this project

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Partnership with the American Heart Association (AHA)

HSX is partnering with AHA to study the disease burden of heart failure across our region in an effort to improve post-hospital discharge care coordination. 

Philadelphia Diabetes Prevention Collaborative

Philadelphia Diabetes Prevention Collaborative

HSX is a partner in the Philadelphia Diabetes Prevention Collaborative run by the Jefferson School of Population Health. Under this program, HSX mined its Clinical Data Repository (CDR) to identify patients with prediabetes based on clinical diagnoses and lab results and provided outreach rosters to health systems participating in the collaborative. HSX also mapped the prevalence of prediabetes by zip code throughout the region to identify neighborhoods with clusters of patients that did not currently have local Diabetes Prevention Program capacity. Learn more about the collaborative here.

Several other population health initiatives are in the HSX pipeline. For further information, please refer to HSX’s Population Health Use Case.