Affinity Health Plan |
SOMOS Your Health IPA |
Northern Manhattan Improvement Corporation |
Economic Stability (Housing instability, Food insecurity, Economic instability) |
SDH intervention focus on assisting patients to maximize entitlement support, incentivize medication adherence and to mitigate the impact of housing and food insecurity through direct service delivery and referrals. |
Bronx, Brooklyn Manhattan, Queens |
Affinity Health Plan |
CHIPA |
AIRnyc - Home visiting service provider Association for Energy Affordability (AEA) - Home remediation service provider |
Health and HealthCare |
A comprehensive asthma intervention that addresses environmental needs in the home for families on Medicaid by providing the following main components: (1) Assessment and monitoring of patients with asthma, (2) Education about asthma self-management, (3) Control of environmental exposures that affect asthma, and (4) Medications to treat asthma. |
All Five NYC Boroughs |
CDPHP |
Adirondack ACO |
Comfort Food Community of Washington County (CFC) |
Economic Stability |
The intervention will provide individualized assistance for Medicaid members with identified food insecurity issues. Program staff will assist members in locating food pantry or free community meal resources that meet the member´s individual needs from an accessibility, timing and nutritional perspective, whenever possible. |
Washington, Warren, Saratoga |
CDPHP |
Delta Dental |
The Food Pantries for the Capital District (TFP) |
Economic Stability |
The intervention will provide individualized assistance for Medicaid members with identified food insecurity issues. Program staff will assist members in locating food pantry or free community meal resources that meet the member´s individual needs from an accessibility, timing and nutritional perspective, whenever possible. |
Albany, Schenectady, Rensselaer and Saratoga |
CDPHP |
Various EPC Provider |
The Food Pantries for the Capital District (TFP) |
Economic Stability |
The intervention will provide individualized assistance for Medicaid members with identified food insecurity issues. Program staff will assist members in locating food pantry or free community meal resources that meet the member´s individual needs from an accessibility, timing and nutritional perspective, whenever possible. |
Albany, Schenectady, Rensselaer and Saratoga |
Excellus Health Plan |
Accountable Health Partners IPA, LLC |
Children´s Institute, Inc. |
Health and Health Care |
The project focuses on providing comprehensive screening services to three-year-old children. Screening at the age of three provides the opportunity to identify challenges and successes and intervene accordingly. The program has a well- coordinated, facilitated closed loop referral strategy. Children who screen as at risk or delayed are referred to the appropriate therapeutic resource. |
Monroe |
Excellus Health Plan |
Greater Rochester IPA |
The Center for Youth Services, Inc. |
Health and Healthcare |
Staff members will work with the youth to determine current connections to primary care. If the assessment indicates that he/she is not connected with a primary care provider, the staff member will contact the VBP contractor to facilitate coordination of care. |
Monroe |
Fidelis Care |
Chinese American IPA |
CAIPA Social Daycare (SDC), Inc. |
Health and Healthcare |
The project addresses the behavioral health needs of patients with low socioeconomic status among both adults and children by screening for SDH needs, providing education, and assisting with referral to additional services, such as food banks and housing services. |
All 5 NYC Boroughs |
Fidelis Care |
CIPA Western NY IPA |
Buffalo Urban League |
Health and Health Care |
The intervention targets high-risk pregnant moms, no-shows, and patients who have not been engaged in care for the past 18 months. Clinic providers and staff establish priorities for outreach to high-need patients. |
Erie, Niagara |
Fidelis Care |
Greater Buffalo United Accountable Care Organization |
African Heritage Food Cooperative |
Economic Stability |
The proposed project will target individuals who are diagnosed with either type 2 diabetes or pre- diabetes. Participants´ barriers to healthy eating and regular exercise will be addressed through the a series of integrated strategies. |
Erie |
Fidelis Care (VBP Pilot) |
St. Joseph´s Hospital Health Center Foundation |
Near Westside Initiative |
Neighborhood and Environment |
The primary goal of the intervention is to increase the number of adults in the service area who have access to safe places to exercise. Partners will work to create multigenerational wellness spaces that provide access to physical activity and nutrition resources in their neighborhoods. These efforts will include community engagement sessions, pilot programming, and designing wellness spaces. |
Onondaga |
Healthfirst |
State University Medical Center at Stonybrook |
A.I.R. NYC |
Health and Health Care |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Suffolk |
Healthfirst |
Staten Island University Hospital |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Staten Island |
Healthfirst |
Long Island Jewish Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Queens |
Healthfirst, PHSP |
Interfaith Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Brooklyn |
Healthfirst, PHSP |
Jamaica Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Queens |
Healthfirst, PHSP |
Maimonides Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Brooklyn |
Healthfirst, PHSP |
Mount Sinai Hospital |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Manhattan, Queens |
Healthfirst, PHSP |
NYC-Health and Hospitals Corporation |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Queens, Bronx, Brooklyn, Harlem |
Healthfirst, PHSP |
St. Luke Roosevelt Hospital center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Manhattan |
Healthfirst, PHSP |
Wyckoff Heights Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Brooklyn |
Healthfirst, PHSP |
Beth Israel Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Manhattan, Brooklyn |
Healthfirst, PHSP |
The Brooklyn Hospital Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Brooklyn |
Healthfirst, PHSP |
BronxCare Health System |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Bronx |
Healthfirst, PHSP |
St. Barnabas Health System |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Bronx |
Healthfirst, PHSP |
NYU Langone Hospitals |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Manhattan |
Healthfirst, PHSP |
SUNY Downstate Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Brooklyn |
Healthfirst, PHSP |
Montefiore Medical Center |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Bronx |
Healthfirst, PHSP |
Episcopal Health Services |
A.I.R. NYC |
Health and HealthCare; Neighborhood and Environment; Education |
SDH intervention will focus on improving engagement and asthma self-management for pediatric asthma patients. Community Health Workers (CHWs) will provide baseline and follow- up visits. The baseline is provided to everyone, whereas, the follow up visits are tailored to each family. Each visit entails a mix of intake/data collection, health education, and home environmental assessment. Intervention will also include chronic-disease support, education, and referrals beyond asthma. Care coordination, appointment scheduling and confirmation, and health care planning are also activities of the program. |
Queens |
HealthNow |
Amerigroup IPA |
Homeless Alliance of WNY |
Economic Stability- Housing Security & Stability |
SDH intervention will focus on identifying plan enrollees who are impacted by homelessness. Lead organization will reach out to homeless enrollees or get them assigned a health home (if not already engaged) and will work with collaborating community agencies to identify stable housing opportunities in the community. |
Erie, Genesee Niagara, Orleans, Wyoming |
HealthPlus |
SOMOS IPA |
Northern Manhattan Improvement Corporation |
Economic Stability |
The service delivery goals of the SDH initiative are to assist patients maximize entitlement support, incentivize medication adherence, and to mitigate the impact of housing and food insecurity through direct service delivery and referrals. |
Bronx, Brooklyn, Manhattan, Queens |
HIP |
City Block IPA |
God´s Love We Deliver |
Economic Stability: Food Insecurity |
Potential patients for Medically-Tailored Meals will be referred to address medical diagnosis, symptoms, allergies, medication management and social support systems to attain the best possible health outcomes. CBO will also provide nutritional- counseling and community-based care coordination of the health plan members they serve. |
All 5 NYC Boroughs; Westchester, Nassau |
HIP (Emblem Health) |
AdvantageCare Physicians of New York |
God´s Love We Deliver |
Economic Stability: Food Insecurity |
Intervention will consist of referral for medically- tailored meals in addition to nutritional counseling and community-based care coordination for intervention participants. |
All 5 NYC boroughs; Nassau, Suffolk, Westchester |
HIP(Emblem) |
MediSys IPA |
God´s Love We Deliver |
Economic Stability: Food insecurity |
Intervention will consist of referral for medically- tailored meals in addition to nutritional counseling and community-based care coordination for intervention participants. |
All 5 NYC boroughs; Nassau, Suffolk, Westchester |
HIP/Emblem |
Heritage NY IPA |
God´s Love We Deliver |
Economic Stability |
Program will identify potential patients for medically-tailored meal referral to address medical diagnosis, symptoms, allergies, medication management and social support systems to attain the best possible health outcomes. CBO will also provide nutritional-counseling and community- based care coordination of the health plan members they serve. |
All 5 NYC Boroughs; Westchester, Nassau |
HIP/Emblem |
MediSys IPA |
God´s Love We Deliver |
Economic Stability |
Program will identify potential patients for medically-tailored meal referral to address medical diagnosis, symptoms, allergies, medication management and social support systems to attain the best possible health outcomes. CBO will also provide nutritional-counseling and community- based care coordination of the health plan members they serve. |
All 5 NYC Boroughs; Westchester, Nassau |
HIP/Emblem |
Bronx United IPA |
God´s Love We Deliver |
Economic Stability |
Program will identify potential patients for medically-tailored meal referral to address medical diagnosis, symptoms, allergies, medication management and social support systems to attain the best possible health outcomes. CBO will also provide nutritional-counseling and community- based care coordination of the health plan members they serve. |
All 5 NYC Boroughs; Westchester, Suffolk, Nassau |
HIP/Emblem |
Corinthian IPA |
God´s Love We Deliver |
Economic Stability |
Program will identify potential patients for medically-tailored meal referral to address medical diagnosis, symptoms, allergies, medication management and social support systems to attain the best possible health outcomes. CBO will also provide nutritional-counseling and community- based care coordination of the health plan members they serve. |
All 5 NYC Boroughs; Westchester, Suffolk, Nassau |
HIP/Emblem |
The Montefiore IPA |
God´s Love We Deliver |
Economic Stability |
Program will identify potential patients for medically-tailored meal referral to address medical diagnosis, symptoms, allergies, medication management and social support systems to attain the best possible health outcomes. CBO will also provide nutritional-counseling and community- based care coordination of the health plan members they serve. |
All 5 NYC Boroughs; Westchester, Suffolk, Nassau |
IHA |
CIPA Western NY IPA |
Buffalo Urban League |
Health and Health Care |
The intervention targets high-risk pregnant moms, no-shows, and patients who have not been engaged in care for the past 18 months. Clinic providers and staff establish priorities for outreach to high-need patients. |
Erie; Niagara |
IHA |
Various Providers |
Independent Health Foundation |
Health and Health Care |
Good for the Neighborhood brings healthy living training and tools to assist people in managing and improving their own health. The goals are to encourage residents to develop and maintain an ongoing relationship with a primary care doctor, encourage healthier eating habits, emphasize regular exercise, and encourage individuals to quit smoking. Key program elements include health screenings and measurements, ask the expert, ask the pharmacist, health insurance, a free farmer´s market, and healthy activities for kids. |
Erie and Niagara |
MetroPlus Health Plan |
NYC Health and Hospitals Corporation ("NYC Health + Hospitals") |
God´s Love We Deliver |
Economic Stability |
Home delivery of medically tailored meals ("MTM") approved by a registered dietitian and nutritionist ("RDN"), coordinated through a case management program. |
All Five NYC Boroughs |
Molina Healthcare |
Cayuga Area Plan |
Suicide Prevention & Crisis Services (SPCS) |
Stigma and Discrimination- Provider level intervention |
CBO and VBP contractor will work to actively keep community care providers up to date on available services, promotional events, and strategies and tools to best care for patients living with challenging life situations, thereby promoting a culture of wellness. |
Ithaca, Tompkins Cortland, Schuyler |
Molina Healthcare (VBP Pilot) |
St. Joseph´s Hospital Health Center Foundation |
Near Westside Initiative |
Neighborhood and Environment |
The primary goal of the intervention is to increase access to safe places to exercise. Partners will work to create multigenerational wellness spaces that provide access to physical activity and nutrition resources in their neighborhoods. These efforts will include community engagement sessions, piloting programs, and designing wellness spaces. |
Onondaga |
MVP Health Plan, Inc. |
GRIPA |
Center for Youth Services, Inc. |
Health and Health Care |
Through this program, staff will act as navigators to facilitate access to insurance and care, provide education, and outreach to ensure universal quality access to health care services. The primary focus of the work will be to assess the health care status of clients who utilize the services program. If the assessment indicates that they are uninsured or under-insured or do not have a primary care provider, the staff member will assist in obtaining insurance coverage and a relationship with a provider. |
Monroe |
MVP Health Plan, Inc. |
Mohawk Valley Medical Associates-MVMA |
City Mission of Schenectady |
Health and Healthcare; Social and Community Context |
The primary focus of the intervention will be:
- street-level outreach to the most at-risk, highest - utilizing population
- connecting the under-served individuals and families in the community to healthcare-related resources in conjunction with other social resources
- care coordination for patients in collaboration with partners and providers, offering to patients the unique, personal, & credible support they need to better access healthcare in the proper way
|
Schenectady |
MVP Health Plan, Inc. |
CBH Care IPA |
The Preservation Company |
Economic Stability; Neighborhood and Environment |
Intervention will focus on working with individuals and care teams around homelessness, housing instability, skills to maintain housing, and lack of access to affordable housing. Services will include: developing and circulating resources to support stable housing (including tenant rights and budget management); developing county-specific resource guides for seven counties; developing a process for receiving and tracking housing support services to primary care patients; and providing individual housing support review and application assistance for individuals in need of housing. |
Westchester, Rockland, Orange, Ulster, Sullivan, Dutchess, Putnam |
MVP Health Plan, Inc. |
Middletown Medical |
United Way of Westchester and Putnam, Inc. |
Education; Social and Community Context; Health and Health Care; Neighborhood and Environment; and Economic Stability |
The primary focus of the intervention will be to facilitate direct access to the appropriate community-based organization(s) that can provide direct services to help meet members´ various SDH needs. A helpline will be available for members, and staff will be able to link program members with appropriate community organizations, agencies or services that can help meet their identified SDH needs.meet their identified SDH needs. |
Orange, Sullivan, Ulster |
MVP Health Plan, Inc. |
Montefiore ACO IPA |
United Way of Westchester and Putnam, Inc. |
Education; Social and Community Context; Health and Health Care; Neighborhood and Environment; and Economic Stability |
The primary focus of the intervention will be to facilitate direct access to the appropriate community-based organization(s) that can provide direct services to help meet members´ various SDH needs. A helpline will be available for members, and staff will be able to link program members with appropriate community organizations, agencies or services that can help meet their identified SDH needs. |
Dutchess, Orange, Rockland, Sullivan, Ulster, Westchester, and Putnam |
United Healthcare |
CAIPA Care |
God´s Love We Deliver |
Economic Stability: Food Insecurity |
Provision of medically tailored home delivery meals and nutritional counseling. |
All 5 NYC Boroughs, Nassau, Westchester |
United Healthcare |
Community Health IPA |
God´s Love We Deliver |
Economic Stability |
The intervention consists of home-delivered medically tailored meals that are approved by a Registered Dietitian Nutritionist (RDN) and reflect appropriate dietary therapy based on evidence- based practice guidelines. Diet and meals are recommended by a RDN based on a session of nutrition diagnostic and therapy for disease management (medical nutrition therapy) and a referral by a health care provider to address a medical diagnosis, symptoms, allergies, medication management and side effects to ensure the best possible nutrition-related health outcomes. |
All 5 NYC Boroughs; Westchester, Suffolk, Nassau |
WellCare (VBP Pilot) |
SOMOS Your Health IPA |
Northern Manhattan Improvement Corporation |
Economic Stability- housing instability, food insecurity, and economic instability |
The intervention focuses on referrals for social and health services to improve the health of the priority population. SDH intervention components include assisting patients to maximize entitlement support, incentivizing medication adherence, and mitigating the impact of housing and food insecurity through direct service delivery and referrals. |
Bronx, Brooklyn Manhattan, Queens |
WellCare of New York |
Eastern Chinese American Physician IPA |
Northern Manhattan Improvement Corporation |
Economic Stability |
The organization will identify their high cost, high need members who also have conditions that could be impacted with an SDH intervention. Once identified, staff will perform an initial outreach to the member, conduct a SDH screening, identify potential services and gauge member´s willingness to access services. Facilitation of appointment scheduling will be completed for members. |
Bronx, Brooklyn Manhattan, Queens |
WellCare of New York |
Hudson Heights IPA |
Northern Manhattan Improvement Corporation |
Economic Stability |
The organization will identify their high cost, high need members who also have conditions that could be impacted with an SDH intervention. Once identified, staff will perform an initial outreach to the member, conduct a SDH screening, identify potential services and gauge member´s willingness to access services. Facilitation of appointment scheduling will be completed for members. |
Bronx, Brooklyn Manhattan, Queens |
WellCare of New York |
Bronx United IPA |
Northern Manhattan Improvement Corporation |
Economic Stability |
The organization will identify their high cost, high need members who also have conditions that could be impacted with an SDH intervention. Once identified, staff will perform an initial outreach to the member, conduct a SDH screening, identify potential services and gauge member´s willingness to access services. Facilitation of appointment scheduling will be completed for members. |
Bronx, Brooklyn Manhattan, Queens |
WellCare of New York |
Central Queens IPA |
Northern Manhattan Improvement Corporation |
Economic Stability |
The health partners will be implementing a comprehensive and cost effective program that will focus on housing instability and food insecurity. Organization will identify their high cost, high need members who also have conditions that could be impacted with an SDH intervention. Once identified, case management staff will perform an initial outreach to the member, conduct an SDH screening, identify applicable services, and gauge member´s willingness to access services. Case managers will help facilitate appointment scheduling for services needed. |
Bronx, Brooklyn, Manhattan, Queens |
WellCare of New York |
South Asian IPA |
Northern Manhattan Improvement Corporation |
Economic Stability |
The health partners will be implementing a comprehensive and cost effective program that will focus on housing instability and food insecurity. Organization will identify their high cost, high need members who also have conditions that could be impacted with an SDH intervention. Once identified, case management staff will perform an initial outreach to the member, conduct an SDH screening, identify applicable services, and gauge member´s willingness to access services. Case managers will help facilitate appointment scheduling for services needed. |
Bronx, Brooklyn, Manhattan, Queens |
Managed Long Term Care Interventions |
Aetna Better Health Of NY |
N/A |
AIRNYC |
Social/Community Context, Health and Healthcare |
A community health worker will address isolation and lack of family/community support for members who are eligible based on screening. The CHW will conduct assessments to identify SDH concerns that affects members physical, mental, psychological and spiritual health. The CHW will coordinate with the MLTC care manager and/or risk provider sharing the information obtained from home visits and refer the member to the approrpriate services. |
Manhattan, Brooklyn, Queens, Bronx, Nassau, & Suffolk |
AgeWell New York |
N/A |
Jewish Association Services for Aging |
Education |
The intervention will consist of health literacy education programs targed at nutrition, disease management, mental health well-being, and medication adherence. |
Brooklyn and Manhattan |
Catholic Managed Long Term Care, INC. D/B/A/ ArchCare Community Life |
N/A |
ArchCare Community Services, INC. (Timebank) |
Social, Family, and Community Context |
Members that are identified as lonely and/or depressed will be referred by their provider to the program for assessment. If the care manager feels that the member will benefit from services, a match will be sought. |
All 5 boroughs of NYC and Westchester and Putnam Counties |
Centers Plan for Healthy Living |
N/A |
Achiezer Community Resource Center |
Financial Literacy |
The proposed intervention will cover financial literacy including the following topics: money management, benefits/entitlements for seniors, home equity, and scams and security. |
All 5 boroughs of NYC, Nassau, and Suffolk |
Elderplan/Homefirst |
N/A |
Regional Aid for Interim Needs, INC. (RAIN) |
Health and Healthcare |
This CBO offers a geriatric workforce program that provides training to volunteer educators or one on one educational sessions at their total senior centers on topics aimed at managing chronic health conditions and age-related disorders. |
Bronx |
ElderServe Health, INC. /DBA RiverSpring Health Plans |
N/A |
VISIONS |
Health & Healthcare |
Services of this intervention include instruction in the use of compensatory skills and assistive devices for communication, instruction in daily living skills such as cooking, personal care, leisure activities, and use of optical aids prescribed by an optometrist to enable use of remaining vision. |
Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester |
Elderwood Health Plan |
N/A |
Western NY Integrated Care Collaborative |
Health & Healthcare |
Participants will be enrolled in 1 or 2 evidence based interventions. The two targeted interventions include the Chronic Disease Self-Management Program and the Healthy Ideas Program. |
Erie County |
EverCare Choice |
N/A |
Maternal Infant Service Network |
Health and Healthcare |
The intervention will begin with staff identifying members with high risk and high needs to address poor health outcomes. The plan will collect and integrate SDOH information into individual´s care plan, which will then be shared with staff, member, and primary care provider. |
Rockland, Orange, Dutchess Counties |
Fidelis Care |
Five Star |
Council Center For Senior Citizens |
Education |
The intervention provides education to senior citizens on the following topics: physical health/exercise, IT assistance, and nutrition education. |
Brooklyn |
iCircle Services of the Finger Lakes |
N/A |
Western NY Integrated Care Collaboration |
Social, Family, and Community Context |
The proposed intervention will address social isolation and depression. The program will: educate older adults and caregives about depression, link older adults to primary care and mental health providers, and empower older adults to manage their depressive symptoms through a behavioral activation approach. |
Orleans, Genessee, Wyoming Counties |
Integra MLTC, INC. |
N/A |
Brooklyn Center for Independence for the Disabled |
Social and Community Context |
The proposed intervention will use community health workers to improve member health outcomes, promote healthy behaviors, reduce unnecessary utilization of healthcare resources, and positively impact quality measures. The intervention will also include a peer support component. |
All 5 NYC Boroughs, Westchester, Nassau, Suffolk |
Kalos Health, INC. |
N/A |
Food Gnomes, LLC |
Economic Stability |
Kalos Health will partner with Food Gnomes, a mobile food pantry, to help bridge the economic and nutritional gaps that some of its member´s face. |
Buffalo. Eastern Erie and Niagara Counties |
Kalos Health, INC. |
N/A |
Hearts and Hands Faith in Action, INC. |
Social, Family, Community Context |
This program will focus on senior companion and transportation services. Connecting members that are experiencing isolation and helping them become involved in their communities. |
Buffalo. Eastern Erie and Niagara Counties |
VillageCareMAX/ Premier |
N/A |
AIR NYC |
Health and Healthcare; Neighborhood and Environment |
Program social workers will provide members with information about the program and introduce member to staff members. The clinical team will assess members, and the contracted CBO will perform a home assessment and provide expert recommendations regarding the member. |
Brooklyn, Bronx, Manhattan, and Queens |
VNA Home Care Options, LLC DBA: Nascentia Health Options, LLC |
N/A |
Companion Home Services, INC. |
Health & Healthcare |
This intervention provides a targeted approach to health literacy specific to palliative care and advance directives. Through the intervention, individuals will be empowered to make informed choices about their care and end of life decisions. |
Cayuga, Oneida, Onondaga, and Oswego |
VNS Choice (MLTC, MAP, FIDA) |
N/A |
Visiting Nurse Service of NY Home Care II DBA (VNSNY) |
Social/Community Context, Health Education |
The Program to Encourage Active Rewarding Lives (PEARLS) is a national evidence-based model designed to reduce depression symptoms and improve quality of life in older adults. There will be multiple sessions that focus on behavioral techniques, including outreach to adults 65 years + with a special focus on those who are homebound, depression screening, and engagement in treatment based on the PEARLS model. |
Manhattan and Queens |
WellCare of NY |
Americare, Inc. and The Royal Care |
Northern Manhattan Improvement Corporation |
Economic Stability; Food Insecurity and Housing Instability |
This program will assist members in maximizing entitlement support and mitigating the impact of housing and food insecurity through direct service delivery and referrals. The organization will identify high cost and high need members, and once identified, these members will be contacted by case management staff to engage in services. Case managers will provide initial outreach to members and conduct an SDH screening, identify applicable services, and gauge willingness to access services. |
Bronx, Brooklyn, Manhattan, and Queens |
Programs of All-Inclusive Care for the Elderly Interventions |
Catholic Health LIFE |
N/A |
Community Music School of Buffalo |
Social and Community Context |
Provide music therapy to PACE members with cognitive impairment that may benefit from intervention through reduction of behavior and improve quality of life. |
Erie County |
Complete Senior Care-PACE |
N/A |
The Senior Companion Program /Volunteer Center at HANCI |
Isolation and lack of family/community support |
Reduce isolation, provide socialization and social supports for those lacking family/community involvement. |
Niagara County |
Eddy Senior Care |
N/A |
City Mission |
Health and Healthcare: Access to Healthcare |
The program will employ ambassadors and health coaches to engage with clients in the field to access their needs and then provide immediate referral to community resources and/or refer client to a Health Coach for addition support. Intervention will help clients navigate and address SDH needs such as housing, food, transportation, health insurance, and accessing primary care. |
Schenectady County |
Fallon Health |
N/A |
Sax Man Slim |
Isolation and lack of family/community support |
Providing musical entertainment which promotes socialization and physical participation. Goal is to promote socialization, prevent depression, loneliness and isolation. |
Erie County |
Independent Living for Seniors. D.B.A., ElderOne |
N/A |
Sisters of Saint Joseph of Rochester, Inc. |
Housing Stability |
The program will offer and provide supportive housing and services at the CBO site for participants and monitor and report utilization of services. |
Monroe, Ontario, Wayne Counties |
PACE- CNY |
N/A |
PAWS of CNY |
Social Isolation |
This program will provide pet therapy, an animal- assisted support system, to participants who are struggling with depression and loneliness. The animal-assisted activities are casual "meet and greet" activities where volunteers and pets visit with the participants to provide therapies. |
Onondaga County |
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