MRT Innovations in Social Determinants of Health Initiative

• Document is also available in Portable Document Format (PDF)

Q1 Please provide your contact information below.

---

Q2 Please describe your company or organizations overall goals and mission.

The Salvation Army, Syracuse Area Services, is a religious and charitable organization serving the Syracuse/Onondaga County community since 1883. The Salvation Army, Syracuse Area Services is dedicated to meeting human needs without discrimination, and so demonstrates the Gospel teachings of Jesus Christ. More than 275 staff provide services to over 38,000 at 17 different community sites. Our annual operating budget of more than $18 million includes over 65 contracts with local, state, federal and private funding sources. We have a stable funding base with a creative blending of funding streams to ensure the continuity of services to individuals and families. We are a full member agency of the Child Welfare League of America and are accredited by the Council on Accreditation.

Our success in providing these services includes the ability to attract staff who are "mission driven," and are willing to do "whatever it takes" to meet the needs of individuals and families. This includes initiating proactive outreach activities, community–based programming and services that take place outside the realm of conventional business hours. The Salvation Army strives to meet individuals and families wherever they are at, including those who have been unsuccessful in more restrictive and more costly alternatives. Our staff possess strong engagement skills coupled with understanding and compassion.

The Emergency and Practical Assistance Services programs are located on the South Side of Syracuse in one of the nations´ poorest neighborhoods. The services are provided to anyone living in Onondaga County, but the majority are residents of the South, North and West sides of Syracuse. The U.S. Census Bureau´s study in 2015 showed that Syracuse has the highest rate of ´extreme poverty´ among blacks and Hispanics in the country, and that this extreme poverty "spread out of Syracuse´s core to the city´s Near South, Near Southwest and North Side." The emergency services programs are targeted to help this population.

---

---

Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

The Salvation Army Food Pantry seeks to develop a Nutrition program that receives referrals from the hospital on patients that are at risk of malnutrition. Our Nutrition Case Manager would visit patient (client) in the hospital develop a nutrition plan with them, provide nutrition education/classes, help with post–discharge instructions, 6–12 months of follow up and transportation. Nutrition Case Manager would also deliver food to elderly and disabled clients through the Nutrition program. Developing this program at our local Food Pantry could be a greater benefit because of all the services we offer. Despite the impact social determinants of health have on a patient´s outcomes and costs, many hospital providers who are now providing these services are not equipped to address housing, economic stability, education, food security, and other social determinants.

It has been proven malnourished (food insecure) patients cost nearly twice as much as their well–nourished peers because they experience prolonged hospitalizations and higher readmission rates, the Health Care Cost and Utilization Project reported in 2016. Understanding where a client lives, their income, education level, job status, and other social determinants of health are critical as providers aim to reduce healthcare costs and unnecessary utilization.

To reduce the costs of food insecurity, Chicago–based Advocate Health Care launched two quality improvement initiatives targeting malnutrition. They started to screen all patients at admission for malnutrition risk. Patients with elevated risk scores received an oral nutritional supplement within two days of admission. They also implemented an enhanced nutrition care program in which high–risk patients received nutrition education, post–discharge instructions, follow–up calls, and coupons for retail oral national supplements. Within six months, Advocate Health Care reduced healthcare costs by $3,800 per patient, resulting in $4.8 million in total savings. They also saw hospital readmission rates drop among patients at risk for malnutrition.

The pantry already has most of the services in place. The additional needs would be for a Nutrition Case Manager and additional life skills supplies for those that do not have the supplies to cook healthy food in their homes. The Salvation Army will continue to work with the local Food Bank, local grocery stores and local Farmers to provide fresh, healthy options in the pantry. Of the current recipients of services in the Food Pantry, 80% of them are on Medicaid, or qualify to enroll in Medicaid. E/PAS has Navigators from the New York State of Health on site and available daily to assist with Medicaid enrollment.

---

---

---

---