MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.


Title and Organization




ZIP/Postal Code

Email Address

Phone Number

Pat Brophy, MD, MHCDS & Dina Faticone, MA

Chair of Pediatrics, Golisano Children´s Hospital; & Director of Community Health, Common Ground Health

601 Elmwood Ave; 1150 University Ave., Bldg. 5



14642; 14607;

585–276–3764; 585–224–3126

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

Golisano Children´s Hospital provides comprehensive care for children and their families in Rochester and the Finger Lakes region with a mission to "Do everything in our power to help every child reach their fullest potential".

Common Ground Health brings together leaders from healthcare, business, education, and other sectors to find common ground on health challenges in Rochester and the Finger Lakes region. Our mission is to bring focus to community health issues via data analysis, community engagement, and solution implementation through community collaboration and partnership.

Q3 Please indicate which category your organization falls under.

Health Care Provider,
Other (please describe below: 150 character maximum):
Common Ground Health is the regional health planning organization for Rochester and the Finger Lakes region.

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).

Call for Social Determinant of Health Innovations:

All Kids Thrive

Need: High–quality early childhood supports have been a long–held priority in Rochester, New York, as demonstrated by the many superior evidence–based programs and services that aid the city´s children and parents through early growth and development, including home visitation, developmental screening, summer learning and universal pre–kindergarten.

Yet despite this robust set of resources, Rochester´s children continue to experience exceptionally poor outcomes. Monroe County remains in the 4th quartile among New York State counties for low birth weight, inadequate prenatal care and asthma hospitalizations for children ages 5–14 years. Further, Rochester City School District is the lowest performing school system in the nation with fewer than 9% of third grade students reading or performing math on grade level and a perennial graduation rate near 50%.

Intergenerational poverty is a core component of this dilemma. Rochester is among the poorest cities in the United States, with a poverty rate of 32.8%. Rochester has the highest rate of childhood poverty (50.5%) and the highest rate of extreme poverty (16.3%) in the nation. Further, 81% of all poor children in the city of Rochester (21,000) live in a female headed household with no husband present.

For those who are vulnerable or living in poverty, accessible and comprehensive systems of support are essential for realizing wellbeing and self–sufficiency. The additional complexity of raising children makes this requisite even more acute. Unfortunately, while there are numerous assets within Rochester´s early childhood system, services are often fragmented by sector and funding stream, capacity is misaligned, and navigation supports are limited. As a result, there are service gaps, failures in the safety net and poor outcomes for children during their most critical stages of development.

Response: In response to this challenge, Children´s Institute, The Children´s Agenda, Common Ground Health, Greater Rochester Health Foundation, United Way of Greater Rochester, and the University of Rochester Department of Pediatrics/Golisano Children´s Hospital have come together to co–create All Kids Thrive, an innovative model of aligned service delivery that is currently being advanced across the greater Rochester community.

The vision of All Kids Thrive is that every child in the greater Rochester area will be developmentally on track and healthy– physically, socially, emotionally and cognitively–from birth to 8 years old. Moreover, under the All Kid Thrive framework, Rochester´s early childhood system will evolve into one that is family centered, universal, integrated, customizable and accountable.

All Kids Thrive includes the concurrent and coordinated implementation of five key strategies:

  • Universal access to coaching and navigation supports for families with children, from conception through age 8
  • Comprehensive developmental screening and accessible follow–up to evaluate, refer and rapidly serve children with developmental needs, across diverse programs and sectors;
  • A universally accessible, year–round, early learning system, staffed by high quality professionals;
  • Family choice of culturally competent providers and support services; and
  • An integrated data system, which allows transfer of critical information across, robust evaluation and longitudinal monitoring across health, early education, education and human service providers.

Central to the development of All Kids Thrive is leveraging opportunities within state and local priorities that have implications for the early childhood system. This includes but is not limited to recommendations from the New York State Department of Health´s First 1000 Days of Medicaid and the New York State Board of Regents Early Childhood Workgroup´s Blue Ribbon Committee, as well as local initiatives such as the Rochester Monroe Anti–Poverty Initiative, Finger Lakes, Performing Provider System, ROC the Future, and the Monroe County System Integration Project. To this end, All Kids Thrive has prioritized eight affiliated objectives:

Objective 1: Expand prenatal and parental support programs, including but not limited to the provision of universal access to family navigation and coaching from prenatal to age 8, and expansion of evidence–based home visitation.

Objective 2: Create a unified, multi–sector system to manage the evaluation and treatment of children with identified developmental concerns, beginning with the expansion of developmental screening initiatives to incent comprehensive screening and closed–loop referral to needed services for children, ages 3 to 8 .

Objective 3: Increase funding for high–quality early care and learning for children, birth to age 3

Objective 4: Create and sustain universally accessible, full–day, year–round, high–quality pre–kindergarten for 3 and 4 year old children. Objective 5: Expand intensive summer learning and out–of–school time services for children, ages 3 to 8.

Objective 6: Create an integrated data system which allows for the sharing and monitoring of critical information across and within the health, early education, education and human service sectors, including use of predictive analytics and appropriate triage to programs based on need.

Objective 7: Support workforce development efforts to ensure highly trained professionals throughout the early childhood system.

Objective 8: Develop community acumen that acknowledges the full range of family supports necessary for children to reach their full potential.

Evidence and ROI: Each All Kids Thrive objective is grounded in evidence–based practice and many have demonstrated significant return on investment. For example, research substantiates that children who attend high–quality early care and education programs (Objectives 3, 4 and 5) are better prepared for kindergarten, have stronger language skills in the first years of elementary school, and are less likely to repeat a grade or drop out of school. In addition, high quality early care and education offers one of the highest returns on public investment– more than $7 for every dollar spent– by reducing future expenditures on special education, public assistance and the criminal justice system. In another example, Nurse Family Partnership, an evidence–based home visitation program (Objective 1) celebrated for its significant positive impact on maternal and infant health, was found to yield a societal benefit cost ratio of 9.6 in New York State. Further, a 2014 RAND study found that a combination of early childhood interventions, such as early childhood education and evidence–based home visitation, particularly when correctly applied based level of risk, had mutually reinforcing positive impacts on return on investments made.

It should also be noted, while it is too early to demonstrate overall value, integration across the early childhood system is gaining traction as an innovative next step towards realization of improved outcomes throughout the lifespan, as evidenced by the focus on Cross–Sector Collaboration throughout the 2017 Roundtable on Population Health Improvement entitled "Exploring Early Childhood Care and Education Levers to Improve Population Health". During this workshop, experts from health, early childhood and education recommended integration across cradle–to–career pipeline, connecting sectoral efforts on brain development, social and emotional learning, and self–regulation, and managing trust at turf issues at the interface between sectors and organizations. All Kids Thrive is a working model to enact these recommendations.

Scalability: A core tenant of All Kids Thrive is the scaling and linking of proven early childhood interventions to create a single coordinated system of service delivery. For example, Objective 2, focused on the screening, referral and management of children with developmental delays, includes scaled implementation of the GROW Rochester model to include all children ages 3–8. Similarly, Objective 5 aims to double the number of high–quality summer learning slots over five years. Moreover, Objective 7 addresses barriers to scalability, namely the shortage of highly skilled professional staff across the child care, early intervention and preschool education systems via the creation of professional development assets.

All Kids Thrive also holds the potential to serve as a pilot for integration of the early childhood system that can be replicated across New York State, as many of the programs targeted under All Kids Thrive are widely adopted across communities and sectors. To support wide– spread scalability, the All Kids Thrive collaborative is committed to monitoring, documenting and sharing key learnings throughout implementation.

Feasibility: All Kids Thrive, while large in scope and scale, was also designed with feasibility in mind. First, All Kids Thrive includes reasonable expansion of existing successful interventions currently operating throughout Rochester´s early childhood system, such as high–quality summer learning and evidence–based home visitation. To this end, the All Kids Thrive collaborative has already enjoyed some success through an infusion of Upstate Revitalization Initiative (URI) dollars that were designated for Rochester Monroe Anti–

Poverty Initiative priorities, including the expansion of early childhood supports.

The URI example also highlights how All Kids Thrive leverages purposeful relationships with high–priority state and local initiatives to set and realize realistic objectives. In most cases, All Kids Thrive does not seek to build new, but instead coordinates opportunities that impact the early childhood system towards a common, widely–held agenda. The relationship between All Kids Thrive and the Monroe County System Integration Project (SIP) is another example of how strategic alignment drives feasibility. In this case, the Monroe County SIP is working to develop an integrated data ecosystem and cross–sector workflows that bridge health, human service and education initiatives.  All Kids Thrive Objective 6 is purposefully aligned with the SIP and is achieved through participation of the All Kids Thrive collaborative in SIP planning and implementation, ensuring that the early childhood system is acknowledged and included in this priority initiative. This model of engagement also reflects Objective 8– develop community acumen– in process.

Relevance to the Medicaid Population: According to the World Health Organization, early childhood is the most important developmental phase of the lifespan, strongly influencing well–being, obesity/stunting, mental health, heart disease, competence in literacy and numeracy, criminality, and economic participation throughout life. Consequently, Early Childhood Education and Development is a priority social determinant of health in New York State, determined to have a significant positive impact on the overall health of the Medicaid population.

All Kids Thrive is designed to scale and connect early childhood interventions and systems that are largely designed to serve those who are vulnerable or living in poverty. As such, All Kids Thrive will have a tremendous impact on the Medicaid population, with a particular focus on pregnant women, parents and children.

Speed to Market: All Kids Thrive has already begun expanded implementation for some of its key strategies. Comprehensive developmental screening and care coordination has been expanded to over 1200 low income 3–year–olds this past year. High quality 6– week summer learning will reach over 700 City of Rochester 3 and 4–year–olds by the end of this summer. The Nurse Family Partnership home visitation program has a current capacity of 250 families, making it one of the largest programs per capita in the US. We can and plan to build on these successes. The Systems Integration Project is a 5–year project currently defining its goals for our community, including children 0 to 8 years. The University of Rochester Department of Pediatrics and Golisano Children´s Hospital has adopted a new strategic plan that includes All Kids Thrive as one of its four strategic pillars and is currently defining goals and measurable outcomes specifically focused on children 0 to 3 over the next 3 years. The Greater Rochester Health Foundation, one of our community´s largest philanthropic funders, has defined its new priority focus for the next 10 years as "Healthy Futures" for children 0 to 8 and will be investing in coaching and navigation services for children and families at birth beginning in 2019. All of these efforts and more will ensure increased access to integrated and effective approaches for young children and families. The work of setting measurable goals and objectives for All Kids Thrive´s key strategies, including timeline and speed to market, is underway and includes representation from each of the organizations above. We will complete this process in the Fall of 2018.

Q5 Was your innovation implemented? If so, please explain when, the number of people impacted, and the results.

Yes (please specify when and the estimated number of people impacted):

Efforts to bring All Kids Thrive to full implementation are underway. Components of the model have been successfully implemented and include:

  1. comprehensive developmental screening and care coordination for 1200 low–income 3–year–olds in 2017–18,
  2. high quality summer learning programs for over 700 City of Rochester 3 and 4–year–olds in Summer 2018, and
  3. successful implementation of Nurse Family Partnership home visitation programs with a capacity to serve 250 families this year.

Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)


Social and Community Context,

Health and Health Care,

Economic Stability

Q7 I give the Department of Health the right to share the information submitted in this application publicly (for example: on the DOH website). I understand that there is no monetary reward/reimbursement for my submission or for attending the summit should my innovation be selected.

I consent to have my innovation shared