New Jersey-based RWJBarnabas Health (RWJBH) has launched an effort to provide a culturally tailored and fully integrated social determinants of health (SDOH) program.
Funded by the Walmart Foundation and the Robert Wood Johnson Foundation, RWJBH has partnered with NowPow, a digital community referral platform, and ConsejoSano, a patient engagement platform that specializes in linguistically and culturally tailored outreach, to develop a program that screens every patient for SDOH conditions, refers and connects them to community services, and provides ongoing support.
Eleven-hospital RWJBH is the largest academic health care system in New Jersey, with a service area covering nine counties with 5 million people. In its Health Beyond the Hospital (HBH) program, some sites within the RWJBH system will pilot the comprehensive program to screen all patients for SDOH, including food security, access to housing, educational opportunities, smoking and substance use, transportation and other social and environmental factors. Just like temperature, weight, or blood pressure, HBH will assess all patients for factors that contribute to chronic disease, removing stigma around questions on housing, safety, or nutrition.
Once a patient is screened, care providers are able to use partner technology to create individually tailored resources based on the patient’s individual needs and “e-prescribe” patients to connect them directly to services and supports, such as the federal Supplemental Nutrition Assistance Program, and community-based programs.
HBH will ultimately be phased in across each RWJBarnabas Health facility in 2021 and will also be fully integrated into the system’s electronic health platform.
“We sought to bring the social determinants into the clinical process. Simultaneously, we are developing a patient-centered approach that serves patients in a consumer-friendly way while paying attention to their culture and language needs,” said Barry Ostrowsky, president and CEO of RWJBarnabas Health, in a statement. “The timely interventions made possible by Health Beyond the Hospital will create a spiral that will positively impact the well-being of our patients and all of those caring for patients across our community.”
RWJBarnabas Health will use NowPow to connect people with personalized services that are highly matched to both their health and social needs, as well as age, gender, eligibility, location, languages spoken, and insurance coverage. HBH will also work closely with community-based and government organizations to close the referral loop, using NowPow to track patient engagement throughout the process so that providers and community-based partners are able to monitor the outcome of referrals and follow-up as needed.
ConsejoSano said it will help reach RWJBarnabas Health patients in the way that makes the most sense for the patient. ConsejoSano provides culturally and linguistically tailored patient engagement and care navigation solutions to payers, providers, and health systems serving diverse patients.