Empowering community-based organizations through real-time data. Home " News " Empowering community-based organizations through real-time data. Healthix completes A pilot to reduce emergency Department overuse for homeless and unstably housed New Yorkers. Executive summary. Emergency Departments (EDs) frequently serve a small but high-need population with complex medical, behavioral, and social challenges - particularly individuals experiencing homelessness or unstable housing. These overlapping needs often drive repeated, avoidable ED visits. By coordinating care more effectively and equipping community organizations with the right information at the right time, New York's health system has an opportunity to improve outcomes, promote stability, and reduce unnecessary costs. Case management and wraparound services are proven strategies for reducing avoidable ED use - but they are only effective when providers know which clients are visiting the ED. To close this gap, Healthix, NYC REACH, and eight housing-focused community-based organizations (CBOs) launched a pilot using two health information exchange services developed by Healthix: * Healthix Focus360: A population health platform that identifies high-risk clients and care gaps. * Healthix Alerts: A real-time ED notification service that instantly informs providers of client ED encounters across New York State. Together, these services empowered New York City Community-based Organizations (CBOs) to identify frequent ED users, intervene earlier, and connect individuals to housing, primary care, behavioral health, and harm reduction services. Early results were strong. CBOs reported improved identification of high utilizers, faster outreach, increased referrals to supportive services, and measurable reductions in ED visits. This pilot demonstrates that timely, integrated patient data can transform community care - improving outcomes for vulnerable New Yorkers while easing pressure on emergency departments. This initiative is the product of a cross-sector partnership among: * Healthix, New York State's largest Health Information Exchange (HIE), aggregating clinical data from thousands of healthcare sites and delivering tools that advance care coordination and value-based care. * NYC REACH, a program of the NYC Department of Health and Mental Hygiene (DOHMH), which supports health IT adoption and care transformation across primary care practices and community organizations. * Eight NYC housing-focused CBOs, serving individuals experiencing homelessness, re-entering housing, or navigating social instability. Through this collaboration, CBO care managers received access to Healthix Focus360 and Healthix Alerts, enabling them to integrate real-time clinical information into case management workflows. NYC REACH supported onboarding, training, and technical assistance to ensure teams could operationalize new data sources quickly. The pilot aimed to strengthen care coordination, promote housing stability, and improve health outcomes for individuals facing significant social and clinical vulnerabilities. Emergency Department overuse remains a significant concern in New York City and New York State, particularly among individuals experiencing homelessness. This population often contends with: * Chronic medical conditions * Behavioral health needs * Substance use * Housing instability * Limited access to timely primary or preventive care Despite a temporary pandemic-era decline of approximately 2% in ED utilization, recent data show a rebound surpassing pre-pandemic levels - with NYC hospitals experiencing a 6.5% increase in ED visits in Q1 2025 compared to Q1 2024. Meanwhile, homelessness in New York has reached historic levels: * More than 91,000 individuals live in NYC shelters. * Statewide homelessness more than doubled between 2022 and 2024. These factors contribute to persistent, high ED utilization for non-emergent issues - reflecting structural gaps in access to coordinated care, housing supports, and behavioral health services. Empowering CBOs with real-time data is both a systems-level and equity-focused strategy to improve outreach, strengthen care transitions, and support healthier lives for those most affected. The pilot focused on embedding two complementary Healthix tools directly into CBO workflows: Real-Time Healthix Alerts. Instant notifications of client ED visits, enabling rapid outreach, post-discharge follow-up, and risk mitigation. Healthix Focus360 reporting. Population health dashboards identifying high utilizers, care gaps, and trends such as ED visit timing, common diagnoses, and patterns across subpopulations. Implementation steps included: * Assessment: Identifying CBO data needs, populations served, and workflow integration points. * Training: Hands-on support from NYC REACH to build competency in both the Alerts platform and Focus360. * Workflow Integration: Embedding alerts into daily operations - case conferencing, outreach prioritization, weekend check-ins, or housing stabilization activities. * Monitoring Impact: Tracking outreach, referrals, and ED visits to evaluate results. The primary goal: use actionable data to intervene earlier, reduce ED dependence, and connect individuals to the right mix of services. Outcomes and insights. Improved identification of high ED utilizers. CBOs quickly pinpointed frequent ED users and recognized emerging trends, including weekend spikes in behavioral health- and substance use - related visits. Faster, more targeted outreach. Healthix Alerts enabled immediate follow-up after ED visits. A Comunilife, Inc. staff member shared: "We've only started receiving alerts in the past five days but finding out that 11 hospitalizations in the past week were due to substance use or psychosis verified my hypothesis that most incidents happen over the weekend." These insights led to proactive strategies such as staff Narcan training, expanded weekend check-ins, and targeted harm reduction outreach. Increased enrollment in social support programs. Over one-third of participating CBOs reported higher enrollment in: * Housing assistance * Behavioral health programs * Substance use treatment * Community stabilization services More referrals to primary care and Mental health services. Several CBOs saw 25%+ increases in primary care and mental health referrals, supported by more accurate and timely client information. Decreased ED visits. Three CBOs documented 10 - 50% reductions in ED visits during the pilot period. Others reported qualitative improvements, such as earlier engagement and more effective care coordination. Pilot program insights: successes and opportunities. Conclusion, recommendations and next steps. This pilot demonstrates the transformative potential of real-time data for improving care and reducing ED overuse among individuals experiencing homelessness or housing instability. By equipping CBOs with actionable information, the initiative achieved: * Earlier intervention * Stronger care coordination * Better connections to medical and social services * Measurable reductions in avoidable ED visits By scaling these insights, New York can strengthen its safety net, improve outcomes for vulnerable residents, and reduce strain on emergency systems - advancing a more efficient, equitable, and data-driven model of community care. Christina Rocchini, MPH, is a strategy and product leader in population health and value-based care. She worked with Healthix through a grant, advancing data-driven solutions to improve care for vulnerable populations. With experience across health tech startups and large health systems, she helps turn complex data into actionable impact. * Piddock, J. (2015, June 8). Quality and SPARCS Data: Where Healthix Inc. is - Where Healthix Inc. is Going? [PowerPoint presentation]. Bureau of Health Informatics, New York State Department of Health. Retrieved from https://www.health.state.ny.Healthix Inc./statistics/sparcs/training/docs/sparcs_nyhima_060815.pdf 1 * Kaufman, M. (2024, September 3). Emergency medical visits on the rise across New York City. POLITICO Pro. Retrieved from https://www.politico.com/newsletters/weekly-new-york-health-care/2024/09/03/emergency-medical-visits-on-the-rise-across-new-york-city-00177007 * New York State Office of the State Comptroller. (2023, October). New Yorkers in Need: Homelessness in New York State. Retrieved from https://www.osc.ny.gov/files/reports/pdf/new-yorkers-in-need-homelessness-nys.pdf

Unite Us Partners with Healthix and Regional Social Care Networks. by Jasmine Pennic 07/10/2023 Leave a CommentWhat You Should Know: Today Unite Us, a leading software company enabling cross-sector collaboration to improve people’s health and well-being, announced a partnership with Healthix, the largest public health information exchange (HIE) in the nation serving New York City and Long Island.Healthix and Unite Us will provide technology to enable communication between healthcare systems and social care networks. Together, they aim to address social drives of health such as food, housing, transportation assistance, and more.Unite Us and Healthix are already collaborating in large social care networks with Public Health Solutions, which provides critical resources directly to New York City’s most underserved populations