How to Build a Comprehensive Social Determinants of Health Initiative

“It is universal because once we get beyond the pilot phase, anyone who comes into an RWJBarnabas facility will be screened for social determinants of health. Some health systems have chosen to limit social determinants of health screening to either the most chronically ill or to those patients with limited income. We have chosen to take a broader view because all patients have social determinants of health and most health outcomes are affected by social determinants,” she says.

Through the Health Beyond the Hospital initiative, RWJBH will be screening for several SDOH, including food and nutrition, living conditions, safety at home, isolation and socialization, and substance use.

In the pilot phase, RWJBH is launching Health Beyond the Hospital in a range of clinical settings to test the initiative, “so that we could build out the proper processes for different settings,” Minus-Vincent says.

The pilot sites include the following:

• An emergency department and inpatient setting in Newark
• A clinic and an ICU in New Brunswick
• A handful of physician practices across New Jersey
• RWJBH Institute for Prevention and Recovery, which has facilities statewide
• RWJBH Children’s Specialized Hospital, which includes several outpatient centers across the state

The pilot phase of the initiative is expected to last about a year, she says.

SDOH assessments and connecting patients to social services

One of the ultimate goals of Health Beyond the Hospital is to make SDOH assessments as routine as assessing patients for height, weight, and blood pressure. Because the initiative is new and the COVID-19 pandemic is surging in New Jersey, RWJBH has contracted with a vendor to help clinicians conduct SDOH assessments, Minus-Vincent says.

“ConsejoSano will do assessments proactively prior to patients coming into a clinical setting. Patients respond to social determinants of health questions so that our clinicians do not have too many questionnaires to do. However, once the assessments become a routine part of our processes, assessments will occur as part of a normal piece of the clinical setting,” she says.

Another vendor will play a key role in referring patients for social services, Minus-Vincent says.

“Once a patient identifies that they have a need, we are working with NowPow, which is a technology tool that has already identified services both in the community and within our RWJBarnabas Health network. NowPow will match needs to appropriate services. For example, if a patient does not know how to prepare healthy foods, needs help with nutritional education, cannot afford food and is not already on SNAP, NowPow could refer the patient to a dietitian in-house. NowPow could get the patient set up with cooking classes and could help with phone-based support to get the patent enrolled in SNAP,” she says.

When NowPow makes a referral, the primary stakeholders are notified, which helps to ensure patients get connected with services, Minus-Vincent says. “The patient knows the organization providing the service, the organization providing the services knows there has been a referral, and the referral goes into the patient’s electronic medical record. So, everybody knows that the patient has selected a particular organization for services.”

If a patient does not connect with a social service, there will be follow-up contact via text, email, or phone calls within a week, she says. “The patient will get a text, email, or phone call noting that they have not received nutritional counseling or another service, and they will be asked questions about whether they need help, such as transportation.”

Monitoring the impact

RWJBH will be following several metrics to gauge the impact that Health Beyond the Hospital has on patients and other stakeholders. Minus-Vincent says those metrics include the following:

• Comparing health outcomes data prior to a patient receiving social services to health outcomes data after social services have been received
• Tracking whether providers and other crucial healthcare workers are being educated about SDOH
• Examining health outcomes of patients by types of providers
• Conducting financial modeling for the initiative
• Monitoring changes in healthcare spend at the patient level
• Tracking whether patients believe they have fewer SDOH after receiving services
• Following whether unnecessary emergency department visits are reduced

“There is a laundry list of metrics that we will be looking at to see how we are changing knowledge base, behaviors, and health outcomes,” she says.

Laying a foundation for Health Beyond the Hospital

There will be two primary educational efforts for the RWJBH healthcare workforce, Minus-Vincent says.

“First, there is a mandatory session for all of our RWJBarnabas Health employees that will educate them about some of the technology tools and available resources. Second, we have developed a program with Rutgers University that is a five-part, guided, virtual series for physicians and intake workers and everyone in between that touches on equity, racism, bias, culturally competent care, and social determinants of health such as food and nutrition, housing, substance use, and violence.”

Education for RWJBH healthcare workers is an essential component of the initiative, she says. “The education is important because we have a great deal of diversity in New Jersey. We have pockets of great wealth and pockets of poverty. Some of our physicians believe few of their patients have social determinants of health, so they are hesitant to do SDOH work.”

When it is fully implemented, Health Beyond the Hospital will have a broad scope, Minus-Vincent says.

“We have created an end-to-end program that includes the relevant stakeholders, with the patient as our true North Star. We also know that if we do not build a program that is easy for our providers to use, it will not get used. And we have thought about how we create a comprehensive program that brings in our government and nonprofit partners. We want to reengineer how the health and social service sectors work together.”