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RWJBarnabas Health launches tech-enabled social determinants of health program

The program is set to begin piloting at select sites in the RWJBarnabas system by completing social determinants of health screenings for patients.

Mallory Hackett, Associate Editor

RWJBarnabas Health has launched its new social determinants of health program, Health Beyond the Hospital, in collaboration with NowPow and ConsejoSano to refer and connect patients to community-based services.

The program is set to begin piloting at select sites in the RWJBarnabas system by completing social determinants of health screenings for patients. It will examine patients' food security, housing, educational opportunities, smoking and substance use, access to transportation and other social and environmental factors.

The goal is to assess patients' risk factors for chronic disease by removing the stigma around questioning housing, safety and nutrition, RWJBarnabas said in a statement.

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Following the screening, providers use NowPow's community referral platform to connect people with services personalized to meet their health and social needs. The platform will take into consideration a person's age, gender, eligibility, location, primary language and insurance coverage to find the best referral. It also tracks patient engagement throughout the process so providers and the community-based organization can follow up as needed.

Using ConsejoSano's patient engagement platform that provides culturally and linguistically-tailored tools, the Health Beyond the Hospital program can serve patients using the communication method that works best for each individual person. It can engage patients through text, phone call, email or mail in over 22 languages.

After the completion of the pilot program, RWJBarnabas will expand the program across its entire system to be fully integrated into its electronic health platform to continue the program in all areas of patient care.


Despite spending an average of 7% more on healthcare than other developed countries, the U.S. has worse health outcomes, including higher rates of chronic disease and infant mortality and lower life expectancy, according to the American Action Forum.

Further, healthcare spending continues to rise in America while population health appears to worsen, the AAF said. For example, in 2016, healthcare spending went up 4.3%, to $3.3 trillion, but the average life expectancy decreased for the second year in a row.

Research has determined that upwards of 80% of someone's health status is determined by factors other than clinical care.

Interventions that have proven effective in alleviating health disparities include programs that focus on early childhood education, urban planning and community development, housing, income enhancements, and employment, according to an article in Health Affairs.


During the pandemic, the social determinants of health were thrust into a position of even more importance after it became apparent that COVID-19 was impacting marginalized groups at higher rates.

Independence Blue Cross and Signify Health launched a similar initiative recently called CommunityLink. Their program is designed to break the barriers between social and clinical care by helping people gain access to nonmedical health services such as food, housing and transportation.

Others have made financial donations to help address the social determinants of health. UnitedHealthcare donated $12.3 million in July to community-based organizations across 21 states as a part of its Empowering Health commitment.

RWJBarnabas also recently integrated with Saint Peter's Healthcare System in New Brunswick, New Jersey, with plans to build a 1,000-bed academic medical center across several campuses.


"What defines our health is so much greater than genetics or clinical care; 80% of all health outcomes are due to social, behavioral, and environmental factors that are the social determinants of health," said Barry Ostrowsky, the president and CEO of RWJBarnabas Health.

"We sought to bring the social determinants into the clinical process. Simultaneously, we are developing a patient-centered approach that serves patients in a consumer-friendly way, while paying attention to their culture and language needs. The timely interventions made possible by Health Beyond the Hospital will create a spiral that will positively impact the wellbeing of our patients and all of those caring for patients across our community."

Twitter: @HackettMallory
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