Posted on: April 24, 2019

Imagine experiencing stomach pain so severe you visit the hospital emergency department (ED) for help. Doctors and nurses conduct all the right tests, but they can’t identify a cause for your distress, so they give you antacids and send you home. A week later, the pain returns—and you’re back in the ED.

Now, imagine if one of those staff members asked you a simple question: “When was the last time you ate?” Your answer could reveal the true problem: painful hunger due to food insecurity, a social problem affecting 40 million Americans, according to federal estimates. Chances are, you would be a familiar face in the ED until that very basic need was met.

“We have to look at the whole person and all of their needs,” says Lori Petersen, business analyst at Alliance for Better Health, a performing provider system (PPS) in New York’s Delivery System Reform Incentive Payment (DSRIP) program. “If we’re sending someone back into their environment, we have to understand what that environment is. That’s why the solutions we’re putting in place and the relationships we’re forging are designed to identify and address barriers that prevent someone who has social needs from meeting those needs.”

Expanding the Definition of Healthcare
Social factors—including substance use disorders, mental health or behavioral issues; access to food, safe housing and transportation; and the ability to understand and follow a doctor’s recommendations—play a big role in each person’s health. In fact, the National Academy of Medicine estimates that social factors may determine up to 90 percent of health outcomes.

That’s why healthcare providers and social service organizations are teaming up to identify the most vulnerable people in local communities and provide them with services that go beyond the exam room. The resulting coalitions link medical providers with food banks, shelters, substance abuse counselors, benefits navigators, medical transportation companies and other community-based organizations.

Alliance for Better Health and other organizations similar to it, such as health homes, serve this purpose. Alliance for Better Health alone connects more than 2,000 medical and behavioral health providers with community-based organizations across six counties to serve Medicaid members holistically and collaboratively.

These groups rely on health information exchanges (HIEs) like Hixny to facilitate communication, referrals and time-sensitive access to patient health records among providers, care coordinators and other stakeholders.

“For the highly vulnerable people we serve, integrated and coordinated service delivery is imperative,” Petersen says. “We can’t be doing it on paper. Without actual data and the ability to connect service providers for continuity of care, we aren’t going to get anywhere.”

Getting Back to Basics
Over the past year, Janelle Shults, director of Capital Region Health Connections (CRHC), a health home serving 3,300 Medicaid recipients in Albany, Schenectady and Rensselaer counties, has led a pilot project to identify social challenges among people who visit the ED.

The most pressing in their sample include transportation, housing, food and the ability to afford medications and doctors’ office visits. And it’s the most basic needs that must be met first.

“If someone has schizophrenia and diabetes and they are homeless, it’s very difficult to engage them in a conversation about managing their schizophrenia and diabetes,” Shults says. “They aren’t worried about doctors’ appointments and medications. Their priorities are where they’ll be sleeping tonight and where they can get their next meal.”

In situations like this, it’s vital to provide help quickly, before people lose connections and individual engagement wanes. Shults calls Hixny a “game changer” in expediting CRHC enrollment, which reflects about 240 community-based referrals each month.

“Previously, we waited for medical providers to send us the records. Sometimes, that could take a while,” she says. “Using Hixny to pull that information immediately has been huge for us.”

Similarly, Petersen says Alliance for Better Health finds Hixny useful in enabling its partners to peer beyond individuals’ often complex self-reported history to identify their needs. As a result, she and her colleagues work closely with Hixny to help social care organizations connect to the HIE.

“No matter which organization is the individual’s point of entry into the collective system, Hixny is very important. Hixny helps that organization understand the person’s whole health history, so the organization can connect that individual to more services,” she says.

This coordinated effort appears to be paying off, Petersen reports. Of the individuals who received crisis intervention services through the Alliance for Better Health network in a recent three-month period, more than 40 percent gained access to primary care and integrated behavioral health providers and only 5 percent required a visit to the ED.

Reducing the Number of Frequent ED Visits
One of the primary goals of both Alliance for Better Health and CRHC is reducing preventable ED use. Both Petersen and Shults agree that Hixny is a key contributor to that effort.

As an example, Petersen said a counselor in an opioid clinic might receive a real-time notification from Hixny that one of her clients checked into the ED. Reviewing his Hixny record, she could see that he was admitted with breathing difficulty and diagnosed with asthma. After her client left the ED, the counselor could follow up to be sure he could afford to get his asthma prescription and take it properly. She could also help him use Alliance for Better Health’s Healthy Together online referral network to schedule a visit with a primary care physician for ongoing asthma care and other services. As a result, he might be less likely to visit the ED.

Is all of the coordination working? It appears to be. Petersen says coordination is a key component in influencing better outcomes. In part by adding data from Hixny to Alliance for Better Health’s connections and programs, the organization has identified a 55 percent reduction in ED use among individuals with housing insecurity over a 12-month period.