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

Tashi Chodon

Director of Programs, Bronx Community Health Network

1 Fordham Plaza, Suite 1108





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

Bronx Community Health Network, Inc. (BCHN) is a non–profit, community–based organization and Federally Funded Health Center, located in Bronx County, NY. Since 1997, our mission has been to provide affordable, quality primary care and related services that teach about healthy living with the goal to promote a community of health and wellness for residents of Bronx neighborhoods. BCHN contracts with Montefiore and Promesa Systems/ Acacia Network for our 21 health center services. Through these service delivery contracts BCHN provides comprehensive, quality, affordable primary medical, dental and behavioral health care, diagnostic laboratory and radiology, health screenings, ob/gyn and family planning, well child services, immunizations, and referrals for substance abuse, specialty and emergency services.

BCHN provides a crucial link to integrating health center clinical care and the important community social support services. We strive to promote disease prevention, early treatment and healthy lifestyles in medically underserved communities. Our nationally recognized Health and Wellness program is designed to connect people with quality, affordable care and to teach about healthy living with the goal to promote a community of health and wellness. We provide care coordination and navigation, screening and enrollment (NYS marketplace enrollment, SNAP, mammogram screening, HIV testing), linkages and referrals (identify community resources such as food pantries, housing, employment, etc.), health promotion and coaching (workshops and health fairs), and home visits. The program is implemented both within our health centers and in the community.

Q3 Please indicate which category your organization falls under.

Community Based Organization

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).

Bronx Community Health Network Inc. (BCHN) proposes to implement Project ECHO for Outreach Workers (PEOW). Project ECHO is a globally recognized evidence–based collaborative model of education and care management linking expert specialists with primary care clinicians in local communities. Specialists represent the "hub" and local clinicians represent the "spokes" in the knowledge–sharing network. BCHN proposes to apply the model using social determinants of health (SDH) specialists to empower outreach workers, non– clinical members of the care team, to provide better care.

PEOW will have two evidence–based tracks:

  1. Case–Based Consultation (evidence–based): Teleconferencing technology will increase outreach workers´ access to SDH specialists at the BCHN "hub". The specialists will provide outreach workers with evidence/practice–based knowledge and support to refer patients/clients efficiently to community resources. Together, they participate in monthly evidence–based teleECHO virtual learning sessions, during which outreach workers from identified organizations ("spokes") present cases, discuss new developments and examine ways to support care plans. Specialists then share evidence–based knowledge and expertise to support and develop outreach workers´ skills for SDH needs – housing, legal or employment. The program is designed to increase the capacity of outreach workers to provide comprehensive, evidence–based best–practice services to address the root causes of chronic health conditions.
  2. Evidence–based Trainings: PEOW partners with subject matter experts for continuing education credits (CE), didactics and evidence– based trainings on health and medical core skills for outreach workers to perform their work efficiently, based on the needs of underserved communities, using evidence–based curricula.

PEOW will provide support in developing outreach workers knowledge in addressing SDH needs to our medically underserved target population, including Medicaid population. There is growing recognition that social and economic factors shape individuals´ ability to engage in healthy behaviors. For example, children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health such as lack of safety, exposed garbage, and substandard housing (see articles below). Further, evidence shows that stress negatively affects health across the lifespan and that environmental factors may have multi– generational impacts. Addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.

From 2003 to 2011, the effectiveness of the ECHO model was evaluated by assessing the impact on rural clinicians participating in teleECHO clinics. Impact measurements included effect on treatment rates, self–efficacy and overall professional satisfaction. The results of this research were first published in Hepatology in September 2010. This article illustrated the ECHO model´s impact to the current healthcare system in three major areas: 1) access to specialty healthcare, 2) expanded delivery of evidence–based best practice care, and 3) a new paradigm for team based interdisciplinary professional development. In addition, Project ECHO subsequently was able to effectively implement a robust expansion of the model to establish its effectiveness, through support from the Robert Wood Johnson Foundation (RWJF). The demonstration project expanded the ECHO model to six additional complex health issues. Each of these new Project ECHO arms demonstrated the need, effectiveness and impact of the ECHO model. Project ECHO currently conducts teleECHO clinics for other chronic conditions such as: chronic pain, integrated addictions and psychiatry, rheumatology, HIV/AIDS, dementia, complex care, palliative care, women´s health/genomics, as well as endocrinology.

PEOW is innovative because the Project ECHO model has never been applied to address non–clinical needs. This project is scalable since the program will be easy to measure, cost is minimal, existing resources can be used with limited time required and is expected to have a high acceptability from stakeholders. PEOW will expand BCHN´s existing Community Health Worker and Patient Navigator program and develop new CBO partnerships and strengthen existing collaboration with over 150 CBO and hospital partners like Montefiore and Acacia Network. This project will ensure efficacy of the current SDH screening and referral initiative within BCHN and beyond and extend the reach of BCHN´s comprehensive evidence–based trainings to all Bronx outreach workers.

By acquiring the knowledge and skills around best practices of addressing SDH needs and making referrals, the outreach workers will better address the root causes of health conditions in the underserved communities of the Bronx. This will lead to improved health care access and utilization by medically underserved patients/clients, thereby improving their health outcomes such as control of high blood pressure, reduction of potentially preventable ER visits and hospital readmissions.

PEOW is a feasible project since it has minimal cost, the technology for program is free and coordination for program can run on existing resources allowing for immediate launch. The teleECHO sessions and evidence–based training sessions will be conducted once per month. By leveraging technology to train those providing care, "specialists" are also better able to triage patients and attend to the most complex, high–risk patients. This creates additional healthcare efficiencies.


  • Complete Orientation/Trainings: Project staff will attend introductory–level orientation events and a more detailed training in evidence– based best practices and tools via an extended visit to the ECHO Institute in New Mexico.
  • Develop and implement evaluation strategy: In tandem with developing the project, BCHN will develop an evaluation strategy for PEOW in collaboration with Project ECHO team at the University of New Mexico.
  • Develop an outline of topics to address for teleECHO sessions/trainings: Use existing evidence–based curricula.
  • Apply for CE Credits: Submit application with curriculum for continuing education credits to the credentialing agency.
  • Recruit Hub Experts: Identify and recruit SDH subject matter experts with the right mentality to be a good mentor.
  • Formally recruit and obtain commitments from Spokes: BCHN will follow–up with identified CBOs and hospitals (spokes) staffed with outreach workers (learners) to explain in detail how the project works and to formally recruit them. BCHN will market the project via print media, brochures/pamphlets and websites.
  • Face to Face ½ day training session: Videoconferencing will be used as a tool for learners to practice presenting and using our case template. It will also include training on the videoconferencing platform.
  • TeleECHO Sessions: These sessions will be conducted at the same time each month to establish a regular routine for our outreach workers.
  • Assessment of project data: The project team will meet quarterly to review all data pertaining to the project collected through pre– and post–test and satisfaction surveys administered at the end of each session. This will allow the project team to dive deeper into trends in the data and adjust to the needs of the learners. Fully implement iECHO, an online data management tool to track the growth and success of the project.
  • Data analysis and publication: This will require engaging the learners and experts via a focus group/survey to analyze and process data and obtain recommendations for next steps. The ECHO Institute will provide observation and feedback.

The IT Support and Administrative Support costs are minimal. After seeing the positive outcomes expected from this project, the spokes organizations who participated in the project should be willing to pay an annual registration fee to provide a potential return on investment. Additionally, by educating health care professionals on SDH, the return on investment from addressing SDH needs of our patients will allow health care system to make health care their first priority, which will lead to a decrease in cost associate with missed visit and cost of health care overall in particular with patient´s disease management. We also expect to bring interested additional spokes organizations in the project which will further support the financial sustainability of the project. Excepted positive outcomes might attract new funding opportunities.

Gopal K. Singh, Mohammad Siahpush, and Michael D. Kogan, "Neighborhood Socioeconomic Conditions, Built Environments, and Childhood Obesity," Health Affairs 29, no. 3 (March 2010)

Vincent J. Felitti et al., "Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study," American Journal of Preventive Medicine 14, no. 4 (May 1998).

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


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


Social and Community Context,

Health and Health Care,

Neighborhood and Environment,

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