RWJBarnabas Health Launches Nation’s First Universal Social Determinants of Health Program

Health Beyond the Hospital Fully Integrates End-to-End SDOH for Tailored Patient Care

West Orange, NJ, October 13, 2020 – RWJBarnabas Health (RWJBH) has launched Health Beyond the Hospital (HBH), the nation’s first end-to-end, universally applied, culturally tailored and fully integrated social determinants of health (SDOH) program. Funded by the Walmart Foundation and the Robert Wood Johnson Foundation, RWJBH has partnered with NowPow, a personalized digital community referral platform, and ConsejoSano, a patient engagement platform that specializes in linguistically and culturally-tailored outreach, to develop this unique program that screens every patient for SDOH conditions, refers and connects them to community services, and provides ongoing support.

“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 H. Ostrowsky, President and Chief Executive Officer, 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 well-being of our patients and all of those caring for patients across our community.”

Select sites within the RWJBH system will pilot the comprehensive program to screen all patients for SDOH, including food security, access to housing, educational opportunities, smoking and substance use, transportation and other social and environmental factors. Just like temperature, weight, or blood pressure, HBH will assess all patients for factors that contribute to chronic disease, removing stigma around questions on housing, safety, or nutrition.

Once a patient is screened, care providers are able to utilize partner technology to create individually tailored resources based on the patient’s individual needs and “e-prescribe” patients to connect them directly to services and supports, such as the federal Supplemental Nutrition Assistance Program, and community-based programs.

In alignment with the system’s commitment to not only identify but to also address the adverse SDOH, HBH will ultimately be phased in across each RWJBarnabas Health facility and will also be fully integrated into the system’s electronic health platform, providing seamless utilization in all areas of patient care.

Health Beyond the Hospital provides ongoing service and touchpoints between patients and providers to ensure that we are working together to address not just physical and mental health, but also social, economic and other factors that get in the way of thriving,” said DeAnna L. Minus-Vincent, MPA, Corporate Senior Vice President, Social Impact & Community Investment at RWJBarnabas Health. “We all need smart care at the right time that comes in the right form; that is true patient-centered support. RWJBarnabas Health is proud to work with NowPow, ConsejoSano and a wealth of other partners to provide this level of care.”

Using NowPow, HBH will be able to connect people with personalized services that are highly matched to both their health and social needs, as well as age, gender, eligibility, location, languages spoken, and insurance coverage. HBH will also work closely with community-based and government organizations to “close the referral loop,” utilizing NowPow to track patient engagement throughout the process so that providers and community-based partners are able to monitor the outcome of referrals and follow-up as needed.

“At NowPow, we help people know where to go and build the connections to get them there,” said Stacy Lindau, MD, MAPP, Founder and Chief Innovation Officer of NowPow. “Once patients are assessed for social risks, they have the opportunity to discuss the issues that they are facing and understand resources available at both RWJBarnabas Health and community organizations. Then, they are seamlessly connected to the personalized services and providers are able to ensure those services were received.”

Playing a critical role in patient follow up, ConsejoSano will help reach RWJBarnabas Health patients in the way that makes the most sense for the patient. ConsejoSano provides culturally and linguistically-tailored patient engagement and care navigation solutions to payers, providers, and health systems serving diverse patients. It is currently the only health care engagement solution designed to address the needs of multicultural patients in the country.

“ConsejoSano will work with RWJBarnabas Health to engage patients through text, phone, e-mail or mail; patients respond in the way that is most comfortable,” said Abner Mason, Founder and CEO of ConsejoSano. “We have the ability to engage in multiple languages, which are not simply translated from English to over 22 other languages, but culturally adapted to build in cultural nuances and mores, to help people live healthier lives.”

Training across select teams throughout the RWJBarnabas Health system is underway. Upon successful completion of the pilot, HBH will be implemented across the entire system in 2021.

About RWJBarnabas Health
RWJBarnabas Health is the largest, most comprehensive academic health care system in New Jersey, with a service area covering nine counties with five million people. The system includes eleven acute care hospitals; three acute care children’s hospitals and a leading pediatric rehabilitation hospital with a network of outpatient centers, a freestanding 100-bed behavioral health center, two trauma centers, a satellite emergency department, ambulatory care centers, geriatric centers, the state’s largest behavioral health network, comprehensive home care and hospice programs, fitness and wellness centers, retail pharmacy services, a medical group, multi-site imaging centers and two accountable care organizations. In meeting its mission of creating healthier communities, RWJBarnabas Health seeks to address the clinical and social determinants of health, improve health outcomes, promote health equity, and eliminate health care disparities.

RWJBarnabas Health is in partnership with Rutgers University to create New Jersey’s largest academic health care system. The collaboration will align RWJBarnabas Health with Rutgers’ education, research and clinical activities, including those at the Rutgers Cancer Institute of New Jersey - the state's only NCI-designated Comprehensive Cancer Center - and Rutgers University Behavioral Health Care. To learn more, please visit

About NowPow
NowPow’s personalized community referral platform reflects the current COVID-19 operating status for more than 65,000 community services in 15 geographies. NowPow’s referrals are highly matched and filtered, making it easy to connect people to just the right community resources so everyone can stay well, meet basic needs, manage with illness and care for others. NowPow’s unique population health solution also provides deep community resource and referral insights to support process improvement, network health and quality, and care access and experience. Find more information at

About ConsejoSano
ConsejoSano is a patient engagement platform that helps connect payers, providers and health systems with their multicultural Medicaid and Medicare patient populations. The company utilizes multi-channel engagement tools to reach patients in a culturally relevant way that increases engagement, lowers costs, and improves health outcomes. For more information, visit

Contact: Carrie Cristello