A trip to the emergency room for an asthma attack is unnerving; when it’s your child having the attack, it’s downright scary. And if it happens frequently, the ER is probably not the best solution.
The ER doctor can treat symptoms and prescribe medications — but that may not address the reason for frequent asthma episodes.
The underlying drivers of poor health outcomes in Trenton are many, varied, and related to poverty, structural racism, behavioral health, childhood trauma, immigration status and other variables that a traditional medical entity is ill-equipped to address.
In Trenton, 10.8 percent of adults have asthma, consistently higher than the state’s rate of 8.2 percent (2016). Trenton residents visit emergency rooms and are hospitalized for asthma-related issues at twice the rate of Mercer County as a whole.
The cause for frequent asthma attacks often is poor housing conditions with dust and mold, or living near major highways with poor air quality, conditions considered beyond the purview of clinicians. Until now.
A better way to refer patients
Building on our collaboration to create new relationships among our clinical and community partners, Trenton Health Team has introduced a new way to address social determinants of health (SDOH) — economic and social conditions that influence well-being.
Over the past year, THT has been providing our partners access to NowPow, a community resource referral platform. NowPow can be used alone, or integrated with our Health Information Exchange (HIE) to enable users to make referrals based on a client’s health and social needs.
New research by the University of Chicago Medicine suggests resource referral systems such as NowPow may have a role in improving public health.
For healthcare providers, this tool elevates SDOH referrals to the same significance as medical referrals, reflecting the growing recognition that housing and other social conditions are “upstream” factors that influence health. With NowPow, they can prescribe needed medication and refer a patient to a partner community agency providing healthy home assessments and mitigation without having to pick up the phone.
NowPow provides a verified list of more than 350 local health and social services in the greater Trenton area, so users know what is available to meet patients’ needs. Users can track outcomes of a referral; text, email, or print referrals in multiple languages for patients, and send appointment reminders or other follow-ups.
Addressing housing, transportation needs
Since December 2018, THT has hosted five “town hall” meetings introducing NowPow to community partners and currently provides access for more than 106 users representing 23 partner organizations, with more agencies planning to join in upcoming months.
In addition to streamlining efforts to address SDOH for clients, the process of introducing NowPow to a new audience of social service providers and working with partners to implement the platform has created new connections among Trenton’s social service and clinical care providers.
Case managers, social workers and others from seven agencies and THT’s care management team collaborated on an SDOH screening tool for NowPow users to assess housing, transportation, food insecurity and other social needs. This comprehensive tool will help identify and address the “upstream” causes for many of the chronic conditions faced by Trenton residents.
As new research demonstrates the links between socio-economic conditions and health outcomes, clinical caregivers must recognize their role no longer begins and ends with diagnosis and prescriptions. Well-being is more than symptoms, and health hinges on social and economic conditions.
As healthcare professionals, we must work together to find the tools and the time to expand our roles. Only a holistic approach, including partnerships with non-clinical partners, can improve health outcomes in a meaningful and lasting way.