New York's Northwell Health is teaming up with technology company NowPow to tackle nonmedical needs among its Medicaid patients, such as mold remediation for patients with asthma or access to healthy food for those with diabetes. The aim is to address these social determinants to improve patients' overall health outcomes.
To launch the partnership, Northwell will provide NowPow's services to approximately 1,200 Medicaid patients who are part of Northwell Health's Health Home, a care coordination program that provides supportive services for people with significant behavioral health needs. Northwell Health operates 23 hospitals in the New York metro area and serves 2 million people annually, the health system said.
NowPow, based in Chicago, is a community resource network management software-as-a-service platform for health and social service referrals. Stacy Lindau, M.D., a practicing physician and scientist at the University of Chicago, co-founded the technology startup four years ago with the idea of e-prescribing community resources. The platform initially launched with the support of a $6 million grant from the Centers for Medicare & Medicaid Services.
The company's software draws on diagnostic codes in electronic health records to identify patients' most urgent nonmedical issues, such as food insecurity, asthma-exacerbating mold in a person's living space or lack of transportation to a pharmacy or doctor's office. The software uses matching logic and evidence-based proprietary algorithms to recommend community organizations that can help with those particular needs, the company said.
In coordinating assistance, NowPow also takes into account patients' geographic location, their eligibility for services, the languages spoken and other factors.
"We know that medical care alone is not enough to make people healthy," Nancy Copperman, vice president of community health at Northwell Health, said in a statement. "Total health also requires healthy food, a safe place to live and the ability to get to the care you need. By talking to our patients about these issues and integrating NowPow into the care we provide, we can connect people to the tools and resources they need to create truly healthy lives."
Northwell's community-based partners in the Health Home program will also have access to the platform for social service referrals. All referrals can be shared, tracked and coordinated by Northwell's providers and partners, both of which can reach out to patients to encourage them to get the help they need, health system officials said.
NowPow will also be able to "close the loop" on referrals of high-risk patients, providing Northwell and its partners with information on whether patients accessed the resources of the various community organizations. In addition, the company will provide other analytics on community needs and resources.
"This kind of data will allow us to fine-tune the efforts we make for our patients so that we're supporting them more effectively," Ram Raju, M.D., senior vice president and community health investment officer at Northwell, said.
The data from the NowPow platform also will help Northwell Health target its community health investment dollars more strategically by allowing the health system to develop a better understanding of the most pressing issues that are dragging down health outcomes in local neighborhoods, Raju said.
"We are proud to partner with Northwell on this important step in their journey toward treating the whole person, not just the disease," Lindau said in a statement.
Health systems and hospitals across the country are taking steps to strategically address social determinants.
Kaiser Permanente recently announced plans to roll out a new care network to more effectively connect its 12.3 million patients to the community services they need, such as housing, food or transportation. The health system plans to make the network, called Thrive Local, available across its entire system within three years to serve the 68 million people in the communities it serves.
Last year, Chicago-based Rush University Medical Center in partnership with NowPow rolled out a system to "prescribe” nonclinical resources and social services to patients. The system also enables Rush clinicians to electronically monitor whether patients are receiving the recommended support.
The United Way of Metro Chicago also is implementing NowPow's software to help connect people to resources for chronic health and social conditions. With more than 100 community-based organizations in the Chicago area joining the platform, it will create one of the nation’s largest multidirectional community resource referral networks, the organization said.
Payers also are putting stock into addressing social determinants.
Solera Health and Blue Cross Blue Shield Institute are piloting a new program to address the social determinants of health and coordinate regional patient resources. Last week, America’s Health Insurance Plans unveiled a new initiative at its Institute & Expo aimed at convening payers to build solutions to address the social determinants of health. The program will include a learning collaborative that will allow insurers to discuss social health trends and share best practices and projects in which they’ve found success.
According to NowPow executives, the company's platform is grounded in peer-reviewed research on population health. In an independent, third-party evaluation, people who received one or more referrals based on the algorithms used by NowPow were compared to matched controls. Primary care use was higher and hospital admissions were lower for Medicaid patients who received the referrals compared to those who did not.
Emergency department admissions were also lower for Medicaid patients who received referrals compared to those who did not, the company said.