How NYC Health + Hospitals is teaming with a startup to tackle food and housing insecurities

As a practicing physician on the south side of Chicago, Stacy Lindau, M.D., knows all too well how often those who work in healthcare system—from doctors to nurses to social workers—are called upon to find community-based support for the patients they serve. 

"Doing this work without technology is inefficient and frustrating, and it rarely results in high-quality results for the person in need," Lindau told FierceHealthcare.

So eight years ago, with the help of a $5.9 million award from the Center for Medicare and Medicaid Innovation (CMMI), Lindau's research lab in the Biological Sciences Division at the University of Chicago developed a technology tool to link patients to community services.

The idea? Offer a way to prescribe social services the same way doctors can prescribe medications. In 2014, Lindau founded startup NowPow to commercialize the e-prescribing tool that she developed. Lindau is now the company's chief innovation officer.

NowPow, a women-owned and led technology company, works with more than 60 customers including health systems, payers and other non-healthcare agencies in 14 states.

RELATED: Kaiser Permanente building infrastructure to 'connect the dots' for social determinants

The startup is forging a relationship with NYC Health + Hospitals, the largest public health care system in the nation, to help address food and housing insecurities among millions of patients. The partnership also includes OneCity Health, which is the NYC Health + Hospitals Performing Provider System under New York state’s Delivery System Reform Incentive Payment program, the state's Medicaid reform initiative. OneCity Health awarded three community-based organizations $4.3 million to help connect patients to available services that are traditionally fragmented and difficult to navigate, the organizations said in a statement.

According to the New York City Neighborhood Atlas, approximately 5.3 million New York City residents are housing insecure. Food Bank NYC estimates that more than 1.2 million New York City residents are food insecure.

There are valuable social service resources in New York City communities but patients often don't know where to look for them, Israel Rocha, CEO of OneCity Health and vice president of NYC Health + Hospitals, told FierceHealthcare.

Working with NowPow will enable clinicians and community-based organizations to more effectively collaborate. "This is a tremendous resource, through technology, that will help us to close gaps that we felt were difficult or almost impossible to close," he said.

Housing and food navigators will be stationed in all 11 hospitals in New York City's public health system and will use NowPow's platform to check patients' eligibility for services and then match them with the community resources that can best meet their identified needs. 

Patients could be connected to resources such as Safe Haven beds and eviction prevention services for those facing housing insecurities, and food pantries and SNAP enrollment for those facing nutrition challenges. 

RELATED: Northwell Health partners with NowPow to address social determinants among Medicaid patients

Lindau believes the key to improving health is to help patients find resources in their own backyards.

"We've found, through repeated studies, that if you connect people to community-based resources, half of the people who get this information will use it to help other people in their community," Lindau said. "Doing this work is different from a drug or device intervention. If you connect patients to their community, it spreads beyond just the client or doctor. That’s powerful in terms of driving long-term change in communities."

NowPow improves the referral process as its software draws on diagnostic codes in electronic health records to identify patients' most urgent nonmedical issues. The software uses matching logic and evidence-based proprietary algorithms to recommend community organizations that can help with those particular needs, the company said.

OneCity Health will measure the success of the food and housing initiatives based on a series of metrics, Rocha said. Nutrition services programs will use clinical indicators on healthcare outcomes, such as patients' A1C levels. Other programs will rely on self-reporting and monitoring to evaluate patients' ability to access housing services or how effective the program addresses patients' food insecurity issues.

"What's exciting about this program is that we can turn a new page in care and look beyond the hospital bed or the physician's office and look to the overall community. This will enable us to work as one team to help enrich the lives of patients and expand the definition of care," Rocha said.

An evaluation of NowPow's technology by RTI International, an independent third-party evaluator, found higher use of primary care among patients who were "prescribed" community referrals through the NowPow platform. At the same time, hospital admissions were lower for Medicare patients, the assessment found, and emergency department admissions were lower among Medicaid patients.