New Jersey-based RWJBarnabas Health (RWJBH) has launched a culturally tailored and fully integrated initiative to address social determinants of health (SDOH).
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, and refers and connects them to community services and ongoing support. The initiative – called Health Beyond the Hospital – is funded by the Walmart Foundation and the Robert Wood Johnson Foundation.
RWJBH is the largest academic health care system in New Jersey, covering nine counties with five million residents. The Health Beyond the Hospital program will be piloted at select sites to screen patients for food insecurity, access to housing, educational opportunities, smoking and substance use, transportation and other social and environmental factors. The program will assess if these factors contribute to chronic disease while removing the stigma associated with discussions between provider and patient around these social risk factors.
Once a patient is screened, providers will utilize the partner technology to create individually tailored resources and “e-prescribe” patients to services and supports based on their individual needs. NowPow will connect patients with personalized services that are matched to their health and social needs, as well as their age, gender, eligibility, location, preferred language, and insurance coverage. The referrals will be tracked to assess patient engagement and allow providers and community-based partners to monitor referral outcomes and follow-up.
ConsejoSano will help reach patients in a culturally and linguistically tailored fashion that makes the most sense for the patient.
Health Beyond the Hospital will be phased in across all RWJBH facilities in 2021 and will be fully integrated into the health system’s electronic health platform for seamless utilization in all patient care areas. Visit the website for more information on the initiative.