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Imagine: You are 70 years old and have just come home from the hospital after having a heart attack. You are glad to be home but feeling overwhelmed – you will need to change your diet, manage follow-up doctor’s appointments, and figure out how to afford your new medications. You’re beginning to worry that it will be more difficult to afford your living expenses while managing your health.
As you sit at your kitchen table, you face a mountain of paperwork and unopened mail. Then you open a letter that says you might be eligible for assistance to pay for prescriptions. You call the number and are surprised to learn that you are actually eligible for multiple programs that will help pay for prescriptions and groceries. It’s a quick process to submit your applications over the phone, and when you hang up you feel yourself breathing a little easier. This help will make a big difference.
This is not just a hypothetical story: Benefits Data Trust (BDT) recently took part in an innovative partnership that leveraged health exchange data to make this type of assistance a reality for seniors recovering from a hospital stay. Considering that benefit programs like the Supplemental Nutrition Assistance Program (SNAP) and prescription assistance are proven to support better health outcomes, it is vital to ensure patients leaving the hospital are connected to the benefits for which they are eligible. This blog post describes the central importance of data sharing to identify and reach patients in need of support.
BDT participated in a collaboration this year through the Robert Wood Johnson Foundation’s Data Across Sectors for Health (DASH) program, an initiative that aims to “identify barriers, opportunities, promising practices, and indicators of progress for multi-sector collaborations to connect information systems and share data for community health improvement.” The collaboration brought together a unique constellation of partners for a three-month pilot, including:
The purpose of the pilot was to test an innovative, data-driven strategy to identify seniors who had recently been hospitalized at Mercy Health System, and connect them with prescription assistance (PACE) and other essential benefits like grocery and housing assistance that would support their recovery once they returned home. BDT also provided referrals for other support services, such as the Pennsylvania Patient Assistance Program (PA PAP) Clearinghouse which offers additional help finding prescription assistance.
The project was built on HSX’s access to real-time patient data.The first step was for BDT and HSX to enter into data sharing agreements, which specified how the data could be used to help people get benefits and outlined provisions to protect patient privacy. HSX and BDT then established automated data feeds using a secure file transfer protocol. This allowed HSX to share a list of seniors who had been admitted, transferred, or discharged from Mercy Health System in the previous 12 months, as well as monthly updates of newly discharged patients. BDT worked with PACE to match the data with lists of current PACE and Medicaid enrollees in order to focus outreach on seniors in need of assistance.
This innovative data sharing strategy made it possible to identify more than 10,000 Mercy Health System patients age 65+ who were not currently receiving PACE prescription assistance. BDT sent a letter to each of these households informing them that they were likely eligible for benefits and received 208 responses between May and July 2019. After conducting an eligibility screening over the phone, BDT submitted 141 applications on patients’ behalf for PACE and other benefits – delivering over $250,000 in benefit dollars. These efforts have provided critical support to help seniors afford prescriptions, groceries, and housing.
Although this three-month pilot was smaller and shorter in duration than a typical project at BDT, it provided a powerful proof of concept: health exchange data is a powerful tool to connect people to benefits that support their health and well-being. Evaluation has shown that four in ten Mercy Health patients (41 percent) who responded to outreach were eligible for at least one benefit. Of these individuals, over half (55 percent) were eligible for PACE, the main benefit targeted in the intervention. Another 16 percent were eligible for food assistance through SNAP (formerly known as food stamps) and 13 percent were eligible for Medicare Extra Help, a federal program that helps pay for out-of-pocket costs of Medicare prescription drug coverage.
There is significant potential to build on this pilot in the future. Insights from the first round of outreach can be used to strengthen future iterations; for instance, BDT and HSX could conduct a comprehensive analysis of the characteristics of Mercy Health System patients who responded to outreach and were found eligible for benefits. Incorporating additional data elements, such as diagnoses of chronic disease, could further target outreach to seniors in need of assistance who are likely to respond to this intervention. The pilot has also demonstrated that the timeliness of outreach has a significant impact on the ability to reach patients effectively: the response rate improved by 60 percent when outreach was sent within two months of the patient’s hospital discharge. Sharing data more quickly in the future would allow for more timely outreach, and testing different messages over multiple media (e.g., mail and text) could substantially increase response rates.
This collaboration demonstrates the value of sharing data, with patient consent, among health care entities and social service providers. There is tremendous opportunity to leverage the power of health information exchanges – and the data they collect – to build innovative partnerships that help patients meet their basic needs. By working together to increase access to critical social services, we can improve individual well-being and support better health outcomes.
To learn more about this collaboration, read the joint report from BDT and HSX: Leveraging the Power of Health Exchange Data for Social Service Interventions.