Overview:
In partnership with BJC HealthCare, Freeman Health System, and Mercy, HIDI leveraged Master Patient Indexing (MPI) to link social care referral data from the Unite Us platform with hospital claims across Missouri. This pioneering study explored the alignment between social care referrals and clinical documentation of social needs (SDOH Z codes).

Impact Highlights:

• 91% match rate between social care referrals and hospital claims using HIDI MPI

• 3,208 patients and 3,870 referral cases evaluated across 10 hospitals and three health systems

• Identified major gaps: Less than 50% of patients referred for social care services had corresponding SDOH Z codes documented in their hospital records

• Uncovered key system barriers impacting social care data capture, including limited SDOH screening frequency, referral network availability, and coding inconsistencies

• Demonstrated the need for aligned, multi-source data strategies to fully capture patients’ social needs

Overview:
A Missouri hospital system partnered with HIDI to harness Master Patient Indexing (MPI) and predictive modeling to proactively identify patients at risk of becoming Emergency Department (ED) super-utilizers. By integrating MPI with real-time admission, discharge, and transfer (ADT) data, the hospital system gained the ability to track high-risk patients across facilities and intervene sooner.

Impact Highlights:

• 1.6% of patients accounted for 12% of all hospital inpatient and ED visits statewide, highlighting a significant concentration of resource utilization.

• Real-time predictive alerts were deployed through HIDI’s point-of-care platform to support care teams in initiating timely outreach and care coordination.

• $3 billion in associated charges were identified across the targeted high-risk cohort, providing critical visibility into cost drivers and supporting efforts to reduce avoidable utilization.

• Enabled system-wide coordination to target social, behavioral, and medical risk factors contributing to repeat hospital use.

• Provided actionable insights for care management teams to prioritize high-needs patients and design targeted interventions.

By leveraging HIDI’s Master Patient Indexing (MPI), BJC HealthCare successfully linked fragmented patient records across 55 hospitals to track participants in its Hospital to Housing (H2H) program. This initiative provided transitional housing and comprehensive support services to patients facing housing instability.

Impact Highlights:

• $2.1 million in estimated hospital savings in the first year post-placement

• 30.9% reduction in total hospital visits per patient per year

• 98.6% match rate linking BJC program data with HIDI MPI longitudinal claims

• Improved continuity of care across hospital systems, enabling robust program evaluation