RWJBH Launches New Program to Manage the SDoH

The first end-to-end, universally applied, culturally tailored, and fully integrated SDoH program in the country.

COVID-19 has widened the gaps between the have’s and have-nots, increased health and behavioral disparities, and driven up costs for healthcare organizations. Each day brings no fewer than five reports, white papers, or issue briefs. All of these resources are well-intended, but at this point, everyone is hungry for clear fixes versus validation through more data – and a potentially powerful one has emerged at last.

RWJBarnabas Health (RWJBH) recently launched its Health Beyond Hospital Program. The program is being touted as the first end-to-end, universally applied, culturally tailored, and fully integrated SDoH program in the country. The program is being funded by the Walmart and Robert Wood Johnson foundations, and managed in partnership with NowPow, a personalized digital community referral platform, and ConsejoSano, a patient engagement platform that specializes in linguistically and culturally tailored outreach. The end result is a program that will screen all patients for SDoH, then refer and connect them to necessary community services while providing ongoing support. Here’s how it works:

  • Patients are screened for assorted SDoH, including food security, housing, educational access, transportation, smoking status, substance use, other at-risk behaviors, and other social and environmental factors.  
  • Many systems implement SDoH into electronic health records (EHRs), which helps to triage patients and even complete assessments. However, they don’t do the heavy lifting to get each patient connected to the necessary referrals, whether geared to enhance health, behavioral health, or psychosocial circumstances.
  • After being screened, care providers engage the NowPow platforms to create patient-centered resources based on individual needs, including age, gender, eligibility, location, language, and insurance coverage.
  • Then, the providers “e-prescribe” patients directly to services and supports, including perhaps the federal Supplemental Nutrition Assistance Program (SNAP), community mental health clinics, housing, or other community-based programs.

The goal is ambitious: to close the gaps that often emerge between patient-identified needs and resource access. Practitioner referral and advocacy are embedded elements to ensure patient linkage, connection, and follow-up interventions. The collaboration with community providers, agencies, and organizations solidifies the power of the initiative, ensuring a higher degree of treatment adherence. A video on the RWJBarnabas website demonstrates the program in action, and is worth the seven minutes to watch.  

The Health Beyond Hospital Program will pilot across RWJBH care sites in the coming months. The outcomes data will be worth watching, specifically how patient program involvement directly impacts hospital utilization and resource management, from emergency department use to admissions, readmissions, length of stay, and of course, costs.

This program is one of many powerful examples of cross-sector collaborations poised to enhance outcomes related to health disparities, as well as to leverage return on investment. Our Monitor Mondays Listeners Survey recently asked who in our audience has cross-sector collaborations in place to address the SDoH at their organization (whether already in place or in the process of development), and the responses appear here.

Programming Note: Ellen Fink-Samnick is a permanent panelist on Monitor Mondays. Listen to her live reporting every Monday at 10 a.m. EST.


Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP

Ellen Fink-Samnick is an award-winning healthcare industry expert. She is the esteemed author of books, articles, white papers, and knowledge products. A subject matter expert on the Social Determinants of Health, her latest books, The Essential Guide to Interprofessional Ethics for Healthcare Case Management and Social Determinants of Health: Case Management’s Next Frontier (with foreword by Dr. Ronald Hirsch), are published through HCPro. She is a panelist on Monitor Mondays, frequent contributor to Talk Ten Tuesdays, and member of the RACmonitor Editorial Board.

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