Social determinants of health are an underlying factor affecting the sustained health of individuals served by Northwell Health. To address these neighborhood-level determinants, Northwell’s Community Health team sought a way to locate and quantify the effects of various determinants on patient health. Using accessible, curated data from PolicyMap, Northwell is developing end-to-end individual and community level social vulnerability risk indices to better inform both providers and patients to improve health in communities in their service area.
Stephanie Kubow manages multiple content areas in her role as Northwell’s Assistant VP in Community Health. Acknowledging that so much of what helps or hinders individual health is influenced by factors outside the healthcare setting, the department is improving health by working to ‘flip the lens’—from traditional individual patient care to a more holistic community view that incorporates social determinants of health. To understand community health factors, Northwell’s Community Health team is developing a Social Vulnerability Index (SVI) of their own, in collaboration with Pieces Technologies, a Dallas, Texas based healthcare artificial intelligence and technology company that connects health systems and communities to address clinical and social determinants of health. Building on PolicyMap’s breadth of Demographic, Quality of Life, and Health data, they are integrating their own anonymized patient level data to determine a level of risk for patients. Ultimately, when patients enter a Northwell Health facility, this Index will allow their care providers to quickly access their community risk and social vulnerability categories in addition to individual medical history. Notably, this index will produce a Patient Risk Score, aimed at identifying risks to flag in a patient’s medical record. With an eye on effective care, Northwell also plans to rank these risks, allowing providers to tackle important issues first –and to identify neighborhoods where risk is most present and strategically use community benefit dollars address the most pressing and actionable identified issues. Once the SVI and Patient Risk Score indices are developed, Northwell plans to aggregate them to view community-level hotspots that illustrate local opportunity and need. Use of PolicyMap informs the Community Health team for their rollout of a true end-to-end care referral platform. By leveraging partnerships with community-based organizations, patient outcomes, and the data in PolicyMap, Northwell Health will employ local data throughout a patient experience – from intake, through service provision, to a data-sourced feedback loop which tracks individual and community outcomes.