Northwell Health announced a partnership with software platform NowPow to better empower patients to get help in overcoming their social determinants of health-the conditions in their daily lives that make it difficult for them to get or stay healthy.

Research has shown that issues like food insecurity, asthma-exacerbating mold in a person's living space or lack of transportation to a pharmacy or doctor's office are powerful predictors of health or illness.  The partnership with Chicago-based NowPow will bolster Northwell's efforts to address these kinds of social determinants by providing patients with highly matched referrals to community resources that can provide relevant help.

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.  Drawing on diagnostic codes in health records, NowPow will identify patients' most urgent, non-medical needs (such as mold-remediation for those with asthma or lack of access to healthy food for those with diabetes), and use matching logic and evidence-based proprietary algorithms to recommend community organizations that can help.  In coordinating assistance, NowPow also takes into account patients' geographic location, their eligibility for services, languages spoken and other factors.  NowPow's Community Resource team validates community organizations before including them in the directory.

"We know that medical care alone is not enough to make people healthy," said Nancy Copperman, vice president of community health. "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 launch will also have full access to NowPow's platform, allowing those organizations to build their own capacity and increase their effectiveness.  All referrals can be shared, tracked and coordinated by Northwell's providers and partners, both of whom can reach out to patients to encourage them to get the help they need.  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," said Ram Raju, MD, senior vice president and community health investment officer at Northwell.  "It will also help us target our 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."

NowPow's platform is grounded in peer-reviewed research on population health. In an independent, third-party evaluation, people who received one or more referral based on the algorithms used by NowPow were compared to matched controls. Primary care use was higher and hospital admissions were lower for Medicare patients who received the referrals compared to those who did not. Emergency department admissions were also lower for Medicaid patients who received the referrals compared to those who did not.

"We are proud to partner with Northwell on this important step in their journey toward treating the whole person, not just the disease," said NowPow's founder and chief innovation officer, Stacy Lindau, MD, MAPP.  "Together we will power the communities Northwell serves with the knowledge everyone needs to stay well, manage their illness, and care for others."