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BLOG: Early Milestones in HARP Research

In recent years, health care providers have recognized patient well-being depends on social and environmental factors not addressed by traditional clinical care. In response, sophisticated data systems, such as NowPow, were developed so health care providers can refer patients directly to food pantries, legal services, faith communities and other social services.

Trenton Health Team has partnered with NowPow to provide access to organizations serving Trenton residents. Too often, however, community organizations providing these services are unable to participate in the referral process — leaving patients with fewer options for assistance.

New research by Trenton Health Team is seeking better ways to integrate social services, public health and healthcare to improve patient outcomes and well-being.

The Highlighting and Assessing Referral Program Participation (HARP) project, launched in May 2020 and funded by the Robert Wood Johnson Foundation will identify barriers preventing community organizations from participating in technology-based referral systems and design solutions and potential facilitators or incentives to participate.

Already, this project has reached several key milestones:

Categorizing levels of engagement 

To understand both barriers and facilitators affecting local organization use of the NowPow referral tool, the research team first had to define engagement to reflect a number of dimensions, including:

  • Are users able to send and receive tracked referrals via NowPow?
  • What is the frequency of NowPow log-ins, and breadth of logins across the organization?
  • Are users following up with tracked referrals they receive?
  • Are users sending tracked referrals, performing social needs screenings, and creating curated referral lists?
  • How timely is the response to tracked referrals, if received?


Next, we assigned point values to each dimension, with points totaled across all dimensions to define a Total Engagement Score. Using this score, THT could label each of the 42 organizations in Trenton as either Engaged (15 organizations) or Not Engaged (27 organizations, including 9 organizations with zero points).

Scores determined which organizations would be Phase 1 interviews, and demonstrated that:

  • Even the most engaged organizations could be more deeply engaged with NowPow
  • Some organizations excelled in some NowPow engagement dimensions, while others excelled on a very different set of dimensions.


The range of scores demonstrated an opportunity not only to  learn how to better engage the “Not Engaged” organizations, but also to develop best practices, along with interventions and incentives, to help community organizations achieve those best practices.

Interviewing Trenton CBOs

The research team conducted an initial round of interviews with front line and executive level organization staff to understand barriers they face using the referral tool and what supports and/or incentives would improve their organization’s engagement. Interviews with communities outside Trenton who have successfully implemented a coordinated care network are also underway.

National Project Steering Committee kick-off meeting

THT in June 2020 hosted a virtual meeting for national and local experts to kick-off the HARP research project. This group will guide different phases of the project, such as developing a structure for CBO engagement models to test later in the project. Organizations represented on this committee include:


The HARP Steering Committee will convene again in November 2020 to review analyses from Phase 1 interviews and discuss engagement strategies for the intervention component of this research.