Northwell Health taps social determinants to improve patient care

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The largest healthcare provider in New York State is leveraging digital software platform vendor NowPow to connect patients to organizations that can help them overcome socioeconomic barriers to health.

The platform is helping Northwell Health support a database of community resources as well as electronic health records and other relevant data that match an individual’s social determinants to highly-matched referrals for needed services.

“NowPow gives us the data to see needs and make decisions, and analytics to help us identify neglected needs,” says Nancy Copperman, vice president of community health at Northwell Health. “Look at the bus routes—they go north and south, but not east and west.”

In launching the platform, Northwell will provide services to 1,200 Medicaid patients who are part of the organization’s care coordination program for persons with significant behavioral health needs. Drawing on diagnostic codes in electronic records, the platform also will identify the most urgent non-medical needs, such as mold-remediation for those with asthma or access to heathier foods for diabetics.

Also See: How to use data, IT systems to address social determinants

Northwell’s community partners will have full access to the NowPow platform to build their own programs to identify needs. All referrals for high-risk patients can be shared, tracked and coordinated, with providers reaching out to patients and encouraging them to get the help they need.

“This kind of data will allow us to fine-tune efforts to support patients more effectively,” says Ram Raju, MD, senior vice president and community health investment officer at Northwell. “It will target community health investment dollars more strategically by allowing us to develop a better understanding of the most pressing issues that are dragging down health outcomes in our neighborhoods.”

The bottom line for Copperman is that too often, providers are throwing life preservers to patients, but as they go down the river, some may lose their preserver. “So, how do we pull people out of the river and put them on land?”

Like many other providers, she acknowledges that Northwell has had trouble in the past reaching underserved populations.

“We can transplant any organ but we aren’t addressing social determinants of health as well as we could to achieve total health for people and the communities we serve,” Copperman contends.

However, she notes that social determinants are not being ignored as the organization is developing partnerships with other stakeholders to connect people to the services they need, such as a list of food pantries, farmer markets, and supermarkets in underserved areas, or even an interpreter to help a Russian diabetic understand how to control the disease.

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