The IBX Foundation and HealthShare Exchange (HSX) are expanding on the positive results of the Network for Enhancing Social Service Transitions for Seniors (NESSTS) pilot, a regional initiative that demonstrated how connected health and social service systems can improve care coordination and access to services for older Philadelphians living with prediabetes or diabetes. NESSTS brought together clinical providers (Delaware Valley Community Health, Spectrum Health Services, Jefferson Family and Community Medicine, and Einstein Community Practice Center) as well as community partners (BenePhilly, Philadelphia Corporation for Aging) to establish data linkages and interoperability among healthcare, benefits, and social service organizations. By connecting existing systems, the pilot enabled providers to better coordinate and manage the clinical and social needs of older adults through a closed-loop referral approach.
Successful social service connections among participating seniors more than doubled, increasing from 20% to 54%. The pilot demonstrated that the capacity of health information exchange to improve care coordination already exists. When healthcare and community-based systems are connected, patients are more likely to access the services they need, validating a scalable model for improved outcomes and whole-person care.
The NESSTS pilot addressed longstanding gaps between benefits agencies, clinical providers, and social service organizations, helping improve coordination, reduce barriers to care, and support better health outcomes while reducing avoidable hospital utilization. Through the work of its Community Health Institute (CHI), the IBX Foundation is supporting HSX in operationalizing a solution that challenges the belief that closed-loop referral is operationally and financially unattainable, while creating a model that can be scaled across Pennsylvania and replicated nationwide.
“By creating a data-connected and coordinated broader network of care providers, HIEs with these expanded capabilities will enable better healthy aging for seniors while benefiting the work of clinicians, and for many seniors, their caregivers and families,” said Heather Major, IBX Foundation president. “As one of the Greater Philadelphia region’s only health funders, we share HealthShare Exchange’s vision to improve health outcomes and build on the success of NESSTs.”
HSX, which already connects hundreds of organizations across the Greater Philadelphia and Delaware Valley area, sees NESSTs as a replicable framework for connecting clinical care, social services, and benefits resources to support whole-person care.
“The NESSTS pilot demonstrated that much of the infrastructure needed to support coordinated care is already in place,” said Greg Liptak, vice president of Innovation and Research at HSX. “By enabling information sharing across healthcare, community-based, and benefits organizations, we can help ensure people receive the services they need while creating a scalable model for closed-loop referrals that can be expanded throughout Pennsylvania and beyond.”
While focused initially on older adults, NESSTS creates a foundation for expanding closed-loop referral and coordinated care to other populations with chronic conditions and social needs. The IBX Foundation and HSX remain committed to advancing connected systems that improve access, coordination, and health outcomes across communities. The IBX Foundation is positively impacting health. In 2026, the IBX Foundation proudly marks 15 years of leading initiatives for a healthier community.
