MRT Innovations in Social Determinants of Health Initiative

SDH Innovation Summit – September 26, 2018

God´s Love We Deliver. Inc.

Medically–tailored meals, paired with nutrition counseling, can radically improve individual health outcomes and reduce overall healthcare costs. God´s Love We Deliver has proven this solution with more than 22 Million meals delivered across the New York metro area so far, including more than 2 Million delivered in partnership with Medicaid Managed Long Term Care providers. Now they are ready to scale this solution further, using shipping carriers and telemedicine to reach severely and chronically ill populations across the state in a high–quality, cost–efficient, proven intervention.

Northwest Bronx Community & Clergy Coalition

The Bronx Healthy Buildings Program (Healthy Buildings) is a collaborative, multi–sectoral approach to developing and implementing a community health initiative led by the Northwest Bronx Community & Clergy Coalition, a 44–year–old grassroots member led organization. The Healthy Buildings Program aims to reduce morbidity among asthma patients living in the Bronx, by holistically addressing several of the upstream causes – health behaviors, social and economic insecurity, and housing conditions – that exacerbate asthma symptoms. Utilizing various sets of data to target buildings, the program goals include: (1) reducing exposure to asthma triggers in apartment buildings through environmental assessment, education, and remediation, (2) reducing greenhouse gas emissions and other pollutants that results from burning fossil fuels, (3) lowering residents´ monthly energy bills by performing energy and water conservation upgrades alongside the health – related remediation efforts, (4) helping residents build community power and leadership through tenant organizing and training about the social determinants of health, and (5) creating jobs and wealth in the community by contracting with Bronx–based construction firms and holding contractors to high – road community workforce standards and ecologically sustainable practices.

Rural Health Network

For 20 years, Rural Health Network has advanced the health and well–being of rural people and communities. Rural Health Network helps build healthy communities by supporting, teaching and coaching individuals on their journey to better health, facilitating or supporting community initiatives, changing systems to improve health across communities and populations, and advocating for public policies that support healthy individuals and communities while recognizing the unique challenges of rural residents and communities. The South–Central NY Fruit & Vegetable Prescription Program enhances the effectiveness of existing clinical and community–based services to prevent and manage chronic diet–related disease by packaging relatively low – cost strategies including vouchers for local produce, nutrition counseling and cooking education, peer support, and transportation assistance to reduce high–cost interventions in the future. The program focuses specifically on cardiovascular disease, diabetes, and associated risk – factors. Participants are referred into the program by healthcare providers and are supported through the program by a Registered Dietitian, Wellness Coordinator, or Community Health Worker over the course of six to eight months.

Socially Determined

Socially Determined are experts in the Social Determinants of Health (SDOH) and their impact on clinical and financial outcomes. As physicians and healthcare experts, they know that outcomes do not come from expert clinical advice only. When they harness the outcome power of Social Determinants of Health – and meet the social needs of real life – they can expect to see improved health outcomes. Socially Determined is unwavering in their mission to improve health and healthcare for patients and families. They know that the solutions lie in the integration of social and clinical data combined with tangible, patient – centered interventions.

Unite US

The Healthy Together Referral Network is a community–wide network led by Alliance for Better Health and powered by the Unite Us technology. The Network enables health and community providers to electronically refer between each other and close the loop on every intervention, while enabling all organizations to work together around every patient as one community care team ensuring the client´s holistic needs have been addressed. The Unite Us technology not only enables for community–wide care coordination, but it also tracks every patient´s total health journey while reporting on all tangible outcomes across a full range of services in a centralized, cohesive, and collaborative ecosystem. Together, Alliance for Better Health and Unite Us are leading the way for other cities and states across the country by fostering collaboration across sectors and regions to improve to health and wellbeing for all.


VillageCare is a pioneering and innovative continuing care organization that offers post – acute care, community services and managed care options to people living in New York City. For over forty years, VillageCare has acquired extensive knowledge and experience to apply in offering and arranging for services. Programs include VillageCare Rehabilitation and Nursing Center and community–based services that include an Adult Day Health Care program, Community Care Management Health Home provider and VillageCare at 46 and Ten Medicaid Assisted Living Program. Their managed long – term care plans include VillageCareMAX Managed Long – Term Care Plan (MLTC); VillageCareMAX Full Advantage FIDA Plan; VillageCareMAX Medicare Total Advantage (HMO – POS SNP) and VillageCareMAX Medicare Health Advantage (HMO – POS SNP).

VillageCare received a CMS Health Care Innovation Award to develop Rango, a technology–based program for people living with HIV/AIDS designed in increase medication adherence and patient engagement.


ArchCare serves more than 8,100 elderly and disabled individuals of all faiths each year. Its mission is to provide holistic, faith–based care to the elderly, disabled and others in the Archdiocese of New York with chronic illnesses who cannot fully care for themselves. The system includes five nursing homes, home care services, a Program of All – inclusive Care Program for the Elderly (PACE), assisted living, health plans, a Long Term Acute Care Hospital, hospice and other community–based programs, including the ArchCare TimeBank.

The ArchCare TimeBank is free volunteer service exchange program that promotes social cohesion and empowers marginalized New Yorkers to meet their own needs and those of their neighbors by sharing their talents and time through a supportive community network. ArchCare is leveraging its TimeBank services as a value – added component of care through its Medicaid Managed Long Term Care Plan (MLTC) and Program of All – inclusive Care for the Elderly (PACE) to address loneliness and depression and its negative toll on the health of frail, isolated and low – income elders. The intervention includes regular exchanges with plan members over the phone and/or face – to – face and has resulted in significant improvements in self – reported physical and mental health and reductions in loneliness.

Family Health Centers at NYU Langone:

The Family Health Centers at NYU Langone´s mission is to improve the health of underserved communities by delivering high – quality, culturally – competent health care and human services. Their nine family health centers, 34 school–based health centers, and over 20 community–based programs serve 100,000 community residents a year. Central to this mission is their work to reduce barriers and address social determinates of health including economic stability, adequate housing, safety, and civic participation, and quality education. As such, the Family Health Centers at NYU Langone has worked collaboratively with several public schools in New York City as a key partner in the Community Schools model (aka Community Learning Centers), an approach that aims to have an impact on the entire population within the community, not just the students enrolled in the school; therefore, they provide an opportunity to improve overall community health. The Community School models works to improve students´ academic performance, and to engage students, teachers, family and community members in creating a positive culture that transforms the school site into a thriving hub of supports and activities that meet the needs of families in low – income neighborhoods; thus, leading to improved student learning, stronger families and healthier communities.

Montefiore Health System

Montefiore Health System is one of the largest providers of Medicaid and Medicare services in New York State, with 1.3 million Medicaid beneficiaries and 433,000 Medicare beneficiaries living in the four counties served by Montefiore and its affiliates. Leveraging the partnerships created through the Montefiore Hudson Valley Collaborative (MHVC) Performing Provider System, Montefiore has been able to expand their provider network throughout the seven Hudson Valley counties. MHVC is a partnership of more than 250 organizations representing a diverse group of stakeholders from hospitals, Federally Qualified Health Centers (FQHC) and Behavioral health organizations, to community–based organizations and public–sector agencies that address the social determinants of health. Together, along with the Bronx Partnership for Healthy Communities (BPHC), they aim to redesign the healthcare delivery system in the communities they serve, and collaboratively transform into an integrated system that seamlessly delivers the right care in the right place at the right time.

Montefiore Health System will present their innovative 3 – pronged, system – wide approach to addressing the social determinants of health: 1) Incentivizing and systematically conducting routine SDH screening; 2) Utilizing an evidence–based referral tool (NowPow) to link patients to CBO–based community resources and services; and 3) Supporting CBOs by providing them with ROI training, coaching and tools including a ROI calculator.

East House

East House´s Affinity Place is a peer run hospital diversion service in Rochester, NY. Administered in collaboration with the Mental Health Association of Rochester (MHA), Affinity Place provides a peer–based, recovery–oriented alternative to existing intensive and costly acute crisis services. Affinity Place guests must be able to benefit from a short – term diversion program and have medial and behavioral health conditions sufficiently managed.

Green & Healthy Homes Initiative

The model creates a set of enrollment criteria based on medical appropriateness where patients have the option to opt out of program enrollment. Attributed patients are delivered services, with the service provider bearing the cost of delivering services. At the end of the payment period, the managed care plan assesses the health and healthcare cost impact for the population using an actuarially sound method, then makes an appropriate payment for the care provided.

NYU College of Dentistry

Bringing Smiles for District 75 has created and established the first school–based dental model for children with special needs in NY State. Their program eliminates barriers (underutilization of services, lack of providers knowledge, limited English proficiency, social and cultural barriers, lack of transportation among others) that prevent parents and children with special needs from obtaining proper access to pediatric dental care.

Services for the Underserved (S:US)

S:US Urban Farms provides therapeutic horticulture, nutritional programming, and employment opportunities to individuals with disabilities through workshops, field experiences, and a network of community farms and garden spaces. Urban Farms functions as an innovative supplement to the support services they offer to individuals, using horticulture as a tool in improving wellness outcomes and in helping their clients to achieve their personal and professional objectives.

Single Stop USA

Single Stop works with community partners to build networks that can provide holistic support to low – income families and individuals. Single Stop service networks are community coalitions that provide streamlined access to social supports for people in need. Based on a shared purpose and mission and with a governance structure to ensure accountability of all members, the networks are efficient and solution–based supports that wrap comprehensive supports around community members in need with a goal of economic self – sufficiency for families and individuals.

Rehabilitation Support Services

Rehabilitation Support Service´s Outreach Team work with long term stay individuals at State Psychiatric Centers in Albany, Saratoga and Dutchess Counties to locate and secure housing, develop innovative residential discharge options allowing them to move out of the hospital and back into their community. Funded by the New York State Office of Mental Health, their outreach program offer community–based, time–limited services for adults with serious mental illness who have experienced long – stays in psychiatric inpatient care. It aims to reduces recidivism rates while providing strategic and intensive outreach to improve one´s access to a community–based system of care, including ambulatory care that will over time meet their emerging behavioral, social and vocational needs.

ACT.MD is a cloud–based care coordination platform that helps connect patients, their families, medical and behavioral healthcare providers, and the community, home–based, and social services that support them on their journey to health and well – being.


The Algorex Health innovation – – founded in the belief that health care organizations need to know about the non – clinical 80% of patient´s lives driving overall health as soon as possible (often before a clinical encounter occurs) – – identifies over thirty member – level SDH stress factors without relying on claims or clinical data. The combination of purpose – built algorithms and SDH stress factors enables Algorex Health to deliver highly – qualified, highly – targeted lists for non – clinical operational interventions at scale.


NowPow, a play on ´knowledge is power´, is a multi – sided self – care referral platform with an array of tools that drive community level collaborations across the entire care continuum. With a focus on referrals to address basic needs and manage with chronic disease, NowPow partners with health systems, health plans, and community–based organizations to conduct SDOH – related screenings, identify self – care needs, facilitate closed loop referrals, support bi – directional patient engagement, and document referral outcomes.

NY e–Health Collaborative

The New York eHealth Collaborative (NYeC) is a 501(c)(3) and the State Designated Entity (SDE) in New York State charged with the leadership, governance, coordination, and administration of the Statewide Health Information Network for New York (SHIN – NY). In that capacity, NYeC works as a public/private partnership with the New York State Department of Health (NYS DOH) on the development of policies and procedures that govern how electronic health information in New York State is shared via the SHIN – NY.

Selfhelp Innovations

Selfhelp a unique, transformational program that engages homebound seniors into the larger community by using technology to connect them with other participants in a range of activities. A cornerstone activity of the program is its interactive, real – time classes where participants can hear, see and talk with each other in an interactive session.

Callen – Lorde Community Health Center

The three agencies created a shared intake form related to social determinants of health, including issues such as violence, stress, access to public resources and depression. The three agencies then created a shared database to collect and analyze this shared data to find gaps in access.

Central Nassau Guidance & Counseling Services, Inc.

The SAH program was a short – term crisis intervention for Medicaid – eligible individuals living with Serious Mental Illness (SMI) in Nassau County and western Suffolk County, NY. Stability at Home aimed to connect individuals with SMI to stable supports in the community and thereby prevent or reduce the utilization of and costs due to avoidable emergency and inpatient services.

Columbia University Center – (MySmileBuddy Program)

The MSBP shifts intervention for ECC from professionally – delivered surgical repair to family – centered disease management through a holistic approach that incorporates social, behavioral, and environmental oral health determinants. The MSBP equips lay health workers with a suite of tablet–based interactive guides, apps, widgets, and videos that assist in engaging parents of at – risk children under age six years of age.

Community Health, Northwell Health

The Food as Health Program will be part of Northwell Health´s Community Health strategy of addressing food insecurity. By having the Food As Health pilot at LIJ – Valley Stream patients can receive food, medical care, nutritional counseling and navigation to food entitlements and community resources to reinforce their self – management of their nutrition related conditions and overall wellness.

Golisano Children´s Hospital

The Fax to Food strategy, involves an active screening and referral process for families that identify food insecurity and need for food assistance during pediatric visits at the Golisano Children´s Hospital at UR Medicine.

New Alternatives for Children, Inc.

Healthy @ Home (H@H) is a program created in 2014 by New Alternatives for Children (NAC) to prevent or reverse the institutionalization of children in long – term care facilities. The children and families served are predominately living in poverty and enrolled in Medicaid. H@H works to improve the health and well – being of two groups of children with complex chronic conditions who, with their families, face staggering challenges.

NYC Health & Hospitals/Gotham Gouverneur

Supporting families – and especially preventing the accumulation of toxic stress – allows them to optimally support the growth and development of their children through the pre – school years. This partnership allowed them to better understand the services available in their neighboring organizations and helped them to develop relationships with key staff members in order to assist in, and streamline the process of effectively connecting patients and families to their wide array of programs.