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Researchers at the University of Chicago Medicine are partnering with NowPow as part of a four-year randomized controlled trial — My Diabetes, My Community — which will test evidence-based interventions for personalized diabetes care in older adults. Using the NowPow platform, the UChicago team is delivering clinical and socioeconomic risk assessments, telephone-based care management, and referrals to community-based resources that assist older adults with diabetes. The partnership reinforces the My Diabetes, My Community mission to evaluate scalable interventions that support personalized care for older adults with diabetes. For more information about the My Diabetes, My Community trial please visit their study website.

The Chicago Department of Public Health and NORC at the University of Chicago, one of the largest independent social research organizations in the United States, are partnering with NowPow to provide resource connections to community members who request services through the CDPH COVID-19 Case Investigation and Contact Tracing programs. Using the NowPow platform, Case Investigators and Contract Tracers refer individuals who test positive for COVID-19 or individuals in close contact with those who test positive, as well as individuals who need to reduce the risk of potential exposure or who have been impacted due to pandemic-related job loss and business closures, to services that provide food, housing, and financial assistance. The partnership ensures that Chicagoans impacted by COVID-19 receive the help they need while keeping community members safe. Read more in this Better Medicare Alliance study.

The NYC Department of Health and Mental Hygiene, one of the world’s largest public health agencies, provided staff at the Javits Center hospital and onboard the USNS Comfort access to NowPow’s platform to extend care for COVID-19 patients. Staff gained access to the platform on both laptops and mobile devices using NowPow’s rapid sign-on functionality. Staff were able to refer patients to community services, such as food delivery, mental health and in-home nursing care, which NowPow verified as operational during COVID-19. This service ensured patients had the support they needed upon discharge to aide self-isolation and recovery.

Healthfirst, New York’s largest not-for-profit health insurer serving 1.4 million members, is partnering with NowPow to address widening gaps in health inequalities during COVID-19. With many of New York’s social services shutting down during the pandemic, Healthfirst’s care managers rely on NowPow’s platform to find resources, in real time, based on members’ ZIP codes to meet their specific needs, such as in-home food delivery. Healthfirst has integrated NowPow’s referral tool into its member-facing mobile app so they can use the tool themselves. Healthfirst is also using NowPow’s interactive COVID-19 Maps to track changes in resources availability over time to better understand supply and demand. Read more in this Fierce Healthcare article.

Erie Family Health Centers, a nationally recognized community health center in Chicago, is using NowPow’s platform to successfully connect patients to vital community services during the COVID-19 pandemic. Within the first three months of the crisis, they successfully connected more than 5,100 patients with services such as food pantries, diaper banks, rental assistance programs, and more. Erie created and added a one-question social needs screener to all telehealth appointments. When resource needs are identified, Erie’s newly formed social determinants of health (SDOH) team follows up by phone and leverages NowPow’s platform to make highly matched referrals to community services that have been verified as operating during COVID-19. Among patients who asked to be connected with resources, the referral success rate has been nearly 80 percent.

Northwell Health, New York’s largest healthcare provider and private employer, quickly expanded its use of NowPow’s NowRx one-way referral tool to address rising needs such as food insecurity and mental health concerns. Northwell was already working with NowPow on a closed-loop referral initiative with select partners for patient populations with complex needs, including chronic conditions, co-morbidities, and mental health and/or substance use disorders. But once COVID-19 hit, Northwell immediately initiated a wider roll-out using NowPow’s rapid sign-on functionality, enabling resource coordinators, social workers, and individuals to address broader social needs and minimize risk among elderly, HIV, and inpatient discharge populations. Read more in this Healthcare Innovation article.

Horizon Blue Cross Blue Shield, New Jersey’s largest health insurer, is partnering with NowPow to address impeding Social Determinants of Health (SDoH) across the state. NowPow is building and managing community resource networks, and serves as a single platform to coordinate and track referrals and vital data among University Hospital, Hackensack Meridian Health, RWJBarnabas Health, Atlantic Health System, St. Joseph’s Health (Health Coalition of Passaic County) and Trenton Health Team. This initiative follows on the heels of a pilot program that showed a 24% reduction in emergency room visits among the group, a 35% increase in behavioral care visits, and their cost of care declined by a quarter. Read more in this NJ Spotlight article.

Illinois Health Practice Alliance, a payor/provider joint venture that includes a clinically-integrated behavioral health network of more than 90 providers, is partnering with NowPow to build a statewide coordinated network to address social needs among the state’s growing population of people with behavioral health needs. NowPow’s advanced consent management functionality is being used to protect both patient privacy and provider time. IHPA is integrating NowPow into its population health platform and rolling the initiative out first among 15,000 Medicaid beneficiaries with co-occurring physical, behavioral health, and social needs with plans to expand in the future. Read more in this NowPow press release.

NYC Health + Hospitals, the largest public health system in the United States, is partnering with NowPow to connect COVID-19 patients with vital community services as part of their hospitals-to-hotels program that gives patients a place to go if they need to be quarantined, but are housing insecure or have a concern about going back to their families. Care professionals work with patients throughout their hotel stay using NowPow to make highly matched, closed loop referrals to social services they know are available to help bridge gaps in physical contact and reduce social risk factors. Read more in this Healthcare Innovation article.

Allina Health, a 12-hospital health system based in Minneapolis with nearly 30,000 employees, is partnering with NowPow to remotely connect patients with vital community-based services during COVID-19. Via the patient portal, Allina sends patients a digital social determinants of health (SDOH) screener. Using the results of that screener, Allina uses NowPow’s platform, which is integrated with the patient portal, to create and share highly matched referrals for community-based services that NowPow has verified as operating during COVID-19. To support its own workforce, Allina also provided the option for their own employees to access NowPow’s platform using rapid sign-on functionality. Read more in this PatientEngagementHIT article.

Rush University Medical Center, a nationally ranked academic medical center in Chicago, and their community partners are relying on NowPow’s platform as the single source of truth for COVID-19 resources in Chicago neighborhoods. Using the platform, they are able to know in real-time what community resources are available to help people get well and care for others. This saves them valuable time, helps to address widening disparities, and gives them access to critical data. Read more in this Fierce Healthcare article.

The Metropolitan Alliance of Connected Communities (MACC), in partnership with Allina Health and Children’s Minnesota, is partnering with NowPow to increase efficiency and create seamless workflows in clinical-community referral connections. Using the FHIR ServiceRequest API (http://hl7.org/fhir/servicerequest.html), NowPow and ClientTrack (through Eccovia Solutions) will integrate such that community-based organizations will receive notifications for new referrals from healthcare partners within their primary source system. The NowPow-ClientTrack integration is a critical step forward in leveling the playing field for all referral partners in the Minnesota caring ecosystem and has been the result of a year of collaborative conversation around clinical-community partnerships.

Northwell Health, New York State’s largest health care provider, is using NowPow to support its care coordination program, Health Home, which includes 1,200 Medicaid patients with behavioral health needs. NowPow users identify patients’ most urgent social determinants of health needs, and NowPow uses custom condition algorithms and matching logic to recommend community organizations and services that can provide relevant help. In coordinating assistance, NowPow also takes into account patients’ geographic location, eligibility for services, languages spoken and other factors.

Both Northwell Health providers and the community partners have access to NowPow’s platform, allowing them to share, track and coordinate referrals. NowPow closes the loop on referrals, telling Northwell Health and community partners if patients successfully connect to services.

Not only can Northwell Health support patients more effectively, but the partnership with NowPow will also help the system better target future community health investments.

NYC Health + Hospitals, New York City’s public hospital system, and OneCity Health, a network of organizations convened for the NYS Delivery System Reform Incentive Payment Program, have collaborated with hundreds of partners to provide NowPow access across the city. Staff members from over 35 NYC Health + Hospitals facilities, NYC Health + Hospitals affiliates (e.g. MetroPlus, its managed care plan and Correctional Health Services) and over 100 OneCity Health partner organizations use NowPow to find the right resources to address unmet social meets for individuals they serve. At NYC Health + Hospitals Gotham Health / Gouverneur in Manhattan, the Pediatrics department is facilitating patient facing social determinants screening using NowPow and connecting families to community resources based on the needs identified. At NYC Health + Hospitals / Lincoln in the Bronx, health advocate volunteers connect patients to SNAP, health insurance, and legal services using NowPow’s tracked referral feature which promotes visibility into the referral outcome. NYC Health + Hospitals / Kings County in Brooklyn also launched an eviction-prevention intervention which involves using NowPow to screen and refer eligible patients to a homelessness-prevention program.

NowPow supports Allina Health with their work under the Centers for Medicare and Medicaid Services Accountable Health Communities (AHC) award. With NowPow seamlessly integrated into Allina’s Epic EHR system, Allina users screen patients to identify health-related social needs and close the gap between clinical and community service providers.

Publicly insured patients who reside in target geographies and self-identify as having one or more social need such as food, housing, utilities, transportation and safety, receive a tailored list of community resources (HealtheRx). HealtheRxs are included in the After Visit Summary and shared with the patient at the point of care, made accessible via the patient portal and saved in the patient’s electronic health record.

Rush University Medical Center has implemented NowPow to support their strategy to care for the “whole person” across their entire system. Rush partnered with NowPow to launch a seamless EPIC-NowPow integrated workflow where over 500 case workers, social workers and other staff members identify patients’ social needs using an enterprise-wise screening, share highly matched referrals with patients and caregivers and close the loop on care with community-based partners. Rush has implemented NowPow in the ER, primary care practices, inpatient medicine and community-based settings. Rush is leveraging NowPow’s closed loop referral technology to connect patients to resources that address their full breadth of social and clinical needs in the community.

Yale Cancer Center and the Yale School of Public Health are taking steps to address health inequities in cancer detection, prevention, and care. The Cancer Disparities Firewall Project targets an underserved population at high risk for cancer in New Haven. The Firewall team utilizes NowPow’s screening functionality to screen for basic social needs. Once needs are identified, NowPow’s resource matching logic generates a HealtheRx, which includes a listed set of community-based resources personalized to the patient’s unique health and social conditions. Patients with identified needs are connected with a cancer care navigator who uses NowPow to document, follow up, and provide additional cancer care resources. By not only identifying barriers to care, but also providing resources and follow up, the Yale Cancer Disparities Firewall is engaging patients around cancer prevention and early detection.

Children’s Minnesota is leveraging NowPow to make highly matched referrals for patients and their families, track resource usage across its two hospital locations, and strengthen partnerships with community providers.
Children’s is currently using NowPow’s closed-loop referral technology with their internal Family Resource Center to address food insecurity among patients and their families. They have seen a rise in families’ access to emergency food resources, an increase from 40% to 83%, and will be launching additional community-based closed-loop referral partners with NowPow.

Healthfirst, a not-for-profit health insurer servicing nearly 1.4 million members in the New York City area, uses the NowPow platform to address social determinants of health (SDOH) needs. Healthfirst care managers use NowRx’s custom-condition algorithm to find highly matched resources for their members across the five Boroughs. This allows Healthfirst to better understand their member population and provide quality shared referrals in the community.

The Trenton Health Team is a community health improvement collaborative serving Trenton, New Jersey. Together with key health partners, they have integrated NowPow with their Health Information Exchange (HIE), allowing healthcare professionals from different organizations to work collectively on behalf of patients and promoting visibility into the patients’ care while reducing the potential for redundant screenings and referrals. By consolidating activity into a unified self care record, NowPow helps users seamlessly identify patients’ health and social needs, share highly matched referrals with patients, and close the loop on care with a growing network of over twenty-five community based organizations.

NowPow supports the Health Coalition of Passaic County with their Pathways to Success care coordination program, based on the AHRQ Pathways Community HUB model. In coordination with over forty organizations, serving the greater Passaic County area, the program targets patients at highest risk for poor health outcomes. The NowPow platform has streamlined the process throughout the community to better align community resources to assist in meeting patients’ needs and connecting them with well-matched referrals. Additionally, HCPC is leveraging NowPow’s needs and tracked referral functionality to track patient follow-up and close the loop on care with community based organizations.

UCare is a nonprofit health plan that employs NowPow’s platform to share community resources with single adults, families and children and people with disabilities in Minnesota. UCare takes a unique approach as a health plan by using NowPow’s self-service platform, FindRx at community events and mobile medical clinic screenings. Current health plan members and potential members can use FindRx to explore resources within their community. By empowering members to identify their needs and utilize NowPow’s hyperlocal directory, UCare motivates members to seek out services. In addition to the self-serve tool, UCare case managers and navigators use NowRx to generate a list of resources for members to overcome any barriers in managing their ongoing care.

Partners in Care (PIC) is the collaborative partnership between The Physician Alliance and Ascension Southeast Michigan, working to provide coordinated care in Michigan. Utilizing the NowPow platform, PIC leverages NowPow’s screening functionality and built in custom condition algorithms to generate and share well matched resources with their patients to address social determinants of health needs. PIC also aims to use NowPow data as a means of analyzing the most common needs impacting their patients and potential resource gaps.

Thrive Chicago uses NowPow to support their community-based Reconnection Hubs. A Reconnection Hub helps Opportunity Youth (young people ages 16-24 who are out of school and out of work) access the resources they need to achieve reconnection back to work or school. NowPow streamlines resource referrals and allows multiple organizations to coordinate care within a unified referral platform, which contributes to seamless connections between system providers.

CommunityHealth, the largest volunteer-based free medical clinic in the nation, delivers high-quality care at no cost to low-income, uninsured patients. The CommunityHealth staff utilizes NowPow in many ways! At CommunityHealth, NowPow is leveraged to close the loop on referrals sent from Rush Medical Center. By streamlining this process, the organization has seen a significant decrease in the appointment no-show rate. The CommunityHealth team also uses NowPow to share highly matched service referrals with their patients and have noticed an improvement in their patients’ diabetes management. They are looking forward to quantifying these results in future evaluations. Stay tuned!