Population Health

HSX partnered with Pathways to Housing PA, a nonprofit that provides housing and support to individuals experiencing chronic homelessness, many of whom face behavioral health and substance use challenges. Using its Clinical Data Repository, HSX delivers daily alerts to Pathways when residents are admitted to or discharged from regional hospitals, enabling real-time care coordination during critical transition periods. These alerts help social workers and clinicians proactively engage with residents to prevent overdoses and support recovery. HSX has also demonstrated improved health outcomes for Pathways residents and found significant reductions in ED visits and hospital stays, along with increased outpatient care. Learn more about the collaboration here.

Metropolitan Area Neighborhood Nutrition Alliance (MANNA) is a non-profit organization based in Philadelphia that provides nutritional support to individuals with major illnesses. MANNA delivers medically tailored meals (Food is Medicine) and provides nutrition counseling to those struggling with serious conditions such as cancer, diabetes, renal disease, and HIV/AIDS. As a Community-Based Organization (CBO) partner of HSX, MANNA receives real-time notifications if one of its clients is admitted to a hospital so they can hold meals and, more importantly, notify MANNA when a client is discharged. HSX has worked with a panel of MANNA clients to measure changes over-time in healthcare utilization and health outcome of people availing themselves of MANNA’s meal service and nutrition plans. Significant reductions were documented in the number of ED visits and hospital stays. So too, reductions in Hemoglobin (A1C) were observed as were improvements in Body Mass Index (BMI). Learn more about the collaboration here.

Connecting PA Seniors with Social Service Benefits

This project is funded by the PA Department of Aging in collaboration with the PACE Screening Center. With the cooperation of HSX member health systems, HSX identifies older adults who may qualify for PACE (the state’s low-cost drug coverage program for seniors) and refers them for potential outreach by the PACE Screening Center. Those who call in are screened for eligibility 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 August 2024, this program identified 2,087 households eligible for benefits, totaling $2.8 million in annual benefits for Pennsylvania seniors from six health systems in our region: Temple Health, Jefferson Health, Penn Medicine, Einstein Health, Main Line Health, and Crozer Health System.

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

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