Marshfield Clinic Health System Launches SDOH Project for Rural Patients

The Wisconsin-based Marshfield Clinic Health System is spearheading a rural health equity initiative in which the organization will leverage technology from community referral platform company NowPow, with the goal to connect patients with local resources.

Marshfield Clinic Health System, one of the largest rural, integrated health systems in the country, will leverage technology from NowPow to identify the social determinants of health (SDOH) needs of patients and community members and provide tools to connect individuals with resources to address these needs, officials said in a recent announcement.

Specifically, the Community Connections Team and Community Resources at Marshfield will use NowPow’s platform to screen patients for five core health-related social needs – housing, food, transportation, utilities and personal safety – along with additional needs such as employment, education, child care and financial strain. NowPow’s platform will then generate a personalized list of highly matched community-based service organizations, such as food pantries, shelters and assistance programs, as well as tools to help connect patients with these resources.

Although there is growing evidence that a significant amount—upwards of 70 percent, according to some research—of a person’s health outcomes is driven by SDOH factors, one 2019 study in JAMA Open Network, inclusive of responses from more than 2,100 physician practices and nearly 800 hospitals across the country, found that just one-quarter of U.S. hospitals and 16 percent of physician practices self-report screening patients for social determinants of health such as food, housing, transportation, utilities, and interpersonal violence needs.

That study’s findings suggested that most U.S. physician practices and hospitals do not report screening patients for key social needs, and it appears that practices serving more economically disadvantaged populations report screening at higher rates. What’s more, federally qualified health centers and physician practices participating in bundled payments, primary care improvement models, and Medicaid accountable care organizations screened more than other hospitals, and academic medical centers screened more than other practices, according to the findings.

The two organizations are now working together to build a comprehensive network of agencies and programs serving northern, central and western Wisconsin, aiming to ensure that individuals have access to all the latest and most relevant community-based resources. This initiative supports the efforts of Marshfield Clinic and its affiliated health plan, Security Health Plan, “to embrace an accountable care model that has been able to lower health system care costs thereby decreasing out-of-pocket care costs for patients and returning money to communities the Health System serves,” officials said.

The NowPow platform allows for the ability to track referrals and encourage individuals to fulfill their self-care goals fosters engagement and provides insight into referral outcomes. This data has the potential to help efforts to map unmet needs in communities, inform future expansion of the referral network and provide a more comprehensive picture of an individual’s health needs, officials assert.

NowPow is a tech company based in Chicago’s Hyde Park neighborhood, where the idea to build community referral networks was born. Today, NowPow’s platform supports community referral networks across the nation.

“The pandemic made more obvious than ever the pervasive inequities that still define life for far too many Americans,” said Susan Turney, M.D., CEO of Marshfield Clinic Health System. “We are proud to be part of a paradigm shift that recognizes a person’s health for the complex picture it is, and works to address the structural inequities and socioeconomic factors that affect it. It is a privilege to partner with NowPow on this work to connect patients and families with needed resources so they can attain their full health potential.”

Rachel Kohler, CEO, NowPow, added, “Marshfield Clinic Health System, which is home to Wisconsin’s largest private medical research institute, shares NowPow’s commitment to research and applying a data-driven approach to population health grounded in science. Americans living in rural areas face a number of risk factors for health disparities, including geographic isolation, limited access to health care specialists and limited job opportunities. We are excited to partner with Marshfield Clinic Health System to address these issues and improve more lives in rural Wisconsin, while also deepening our impact across the state.”