Alerts Combat Social Determinants of Health Issues

Diabetic man finally gets care he needs

Alerts Combat Social Determinants of Health Issues

The Institute for Family Health, a New York City FQHC, has incorporated Healthix Clinical Alerts into hospitalization predictive risk models to identify, intervene and treat complex patients at increased risk for adverse health outcomes.

When the Institute received an alert from St. Luke’s Hospital for an ER visit from Brian*, a 60-year-old diabetic without a stable home who had 130 prior visits to multiple EDs within the year, a care manager rushed to the hospital. She walked Brian to their Harlem facility and immediately began planning his services. That day, the Institute connected Brian to primary and behavioral healthcare providers, helped him apply for SNAP, and placed him in a Bronx homeless shelter.

“A lot of our high utilizers have significant social determinants impacting their use of the healthcare system. With the help of Healthix Alerts we can coordinate care for our neediest patients by offering benefits, including nutrition, employment and housing referrals. Healthix Alerts help us reach the right people with the right services.”

– Michaela Frazier, LMSW, Vice President, Social Support Services

This rapid, high-touch intervention was possible because Healthix Alerts were integrated with the Institute’s risk model, helping them to identify patients most at risk. So, when the Institute received that alert about Brian, they were able to act quickly. Before, providers were unable to connect with Brian during his myriad ED visits and, therefore, were unable to redirect him to the care and services he needed.

*Name changed to protect client’s anonymity

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