MRT Innovations in Social Determinants of Health Initiative

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

Q1 Please provide your contact information below.


Title and Organization




ZIP/Postal Code

Email Address

Phone Number

Vasundhara Kalasapudi

Executive Director

178–36 Wexford Terrace Suite 2C





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

With passion and purpose, India Home aims to enrich the lives of vulnerable South Asian older adults of South Asian origin through culturally appropriate services, advocacy and community building activities.

India Home´s mission is to improve the quality of life for vulnerable elders of South Asian origin in New York, who find themselves socially isolated and struggling to access necessary social services. We realize our mission by offering culturally appropriate direct services, individualized case management and care coordination, educational, creative and recreational programs to combat social isolation, as well as research and policy, advocacy and awareness campaigns at both city and state level. Our work includes health and wellness education, financial and legal literacy, creative aging programs, broader community building and engagement, and advocacy and awareness around the needs of the elders we serve.

India Home innovative model of providing senior services has us partnering with existing mainstream centers such as Sunnyside Community Services (SCS), Services Now for Adult Persons (SNAP), and Queens Community House – Kew Gardens (QCH–KG), thus going to where seniors are rather than have them come to us. At these centers, India Home provides a range of direct services including congregate meals to approximately 200–250 seniors a week during. Other activities include but are not limited to: culturally appropriate exercise classes including yoga and meditation; health and wellness and creative aging programs, lectures, discussions, intergenerational programs. Through our programs and outreach, India Home has touched the lives of over 1000 South Asian seniors. India Home is one of the few secular pan–South Asian organizations that provides regular, weekly services to the South Asian community. We have increased senior center participation rates for South Asians and set a standard for other community groups looking to replicate our services. Lastly, we have helped the South Asian community as a whole by bringing seniors´ needs to fore in collaborative efforts such as planning for a South Asian community center and civic action projects.

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).

Our innovative program Holistic Case Management for Healthy Life uses culturally competent Case Workers to connect at risk south Asian seniors to needed health and social services.

The design of the Holistic Case Management for Healthy Life has evolved innovations that are unique in terms of reach, involvement of culturally competent in–community case workers in designing the program, expanded focus to address the broader social determinants of health with targeted outreach, using a flexible program design that actively incorporates feedback from competent community members, pharmacies and providers, and family members in the process.

Setting: Of the South Asian older adults we serve, many are vulnerable new immigrants who live in poverty, depend on adult children, speak little English, have low to no income and are socially disconnected. As new immigrants who have not worked in America they are not eligible for Social Security income. In Queens, which is home to ––– population of immigrants from South Asian countries and most of our clients are on Medicaid.

Community Centered
Our staff are situated within our centers which are located inside mainstream senior centers–thus meeting clients where they congregate rather than expecting clients to come to us. Case workers and navigators are from the community where they work and are familiar with the culture of our clients and fluent in Bengali/Hindi and other South Asian languages.
India Home´s outreach within the wider South Asian community makes it the entry point for identifying potential clients within our centers but also in the broader population. The ongoing outreach has brought us South Asian senior clients from all around the New York City. We have more than 100 clients receiving services and more than 50 referral clients from other boroughs like Manhattan and Brooklyn. Our case workers are trained to not only connect clients with health services but also social services and confirm their connection to these services. Our holistic approach innovatively addresses broader social determinants of health such as education, housing, food security, and immigration assistance.

Our case workers thus not only help with specific health issues but work on a breadth of other social determinants that may affect their client´s health outcomes. This may include housing assistance, immigration issues, and help with accessing social services like Cash Assistance, SNAP or transportation.

Our adaptive design actively seeks and incorporates input from family members, pharmacists and medical professionals in the community. Our integrated approach works with our own organization, other community–based organizations, city agencies and faith–based institutions. India Home´s caseworkers develop extensive personal expertise and skill through participation in the process and through assisting clients and engaging with a wide variety of navigators from diverse agencies like housing to citizenship and immigration.

Personalized case management:
The culturally competent case management services India Home provides is individually tailored to client needs. The case manager reaches out to the seniors in the center to find out their needs, inform them of appropriate benefits and services available for them and assist in obtaining needed services or benefit through referrals and advocacy. The community we are serving has language access and communication barriers. The case management team accompanies clients to the hospitals, doctor´s office or the other offices to advocate for and obtain needed services for them. They assist these members/clients by providing them translation/interpreter services, also provide translated materials to enhance their understanding. Our caseworkers are trained to become interlocutor between cultures. American doctors sometimes do not understand culturally specific terms that are using by the clients, however, the caseworkers can explain what the elder means.
The benefits and entitlement assistance under case management service make the eligible members economically stable. This service provides them food security, housing security and stability and reducing their poverty. Members have Lack of English access and proficiency which affects their daily lives in receiving the services for their own needs. The case management team assist these members by providing them translation/interpreter services, also provide translated materials for their understanding and the seniors can use those when needed. Culturally appropriate materials including modification and adaptation of evidence–based practices, so they are culturally relevant and appropriate. Also, this service encourages eligible members to become the US citizens and make them understand to take civically participate in this society and civic participation helps them to make their voice heard in the community. As some benefits are specifically entitled to the citizens, and their lives will become more stable.

Potential return on investment: The culturally competent case management service has improved the quality of our elders´ lives. Our holistic approach is very popular and has led to an increase in clients from outside of our four centers. We serve 9/10 clients daily. Our service has expanded to all around the five boroughs in New York City. In previous time, the service was only limited to the Senior center members, now this service has expanded outside of the senior centers. Through our senior center programs, we can keep the seniors in the community. As an example, in our center we spend $500 monthly for a senior and they are living a healthy life. On the other hand, if they are living in assisted home facility for a long–term care which will cost ten times more than what we are spending, similarly, it will cost twenty times more if they are living in a nursing home. Therefore, providing holistic case management senior center service are more convenient to the seniors and this has positive impact on their health.

Scalability: This senior center programs has successfully sustaining for last 10 years and the holistic case management service has taken the elders lives in a positive direction. Annually, the program is serving more than 3000 seniors in New York City. The outcomes of this program include reduced rate of hospital admission, reduced length of stay, increased satisfaction by the clients/members, their families, and significantly reduced costs for the hospital, nursing home and assisted home facilities.

Feasibility: The case management cannot be seen as a discrete unit. The holistic case management services are culturally tailored to help the members/clients who have cultural and economic needs. Providing health literacy in their languages and other services can make their lives easier. Now they know how to communicate and what necessary steps need to take for their benefits. We are dealing with everything from their economic stability, food security to health stability.

Relevance to the Medicaid population: At Desi Senior Center, we have around 90 percent members are Medicaid recipients who have low to no income. These seniors rely on Medicaid for their health and long–term care. Some member (aged 65+) have Medicare, and Medicaid helps pay their Medicare premiums, deductible and copays. Without Medicaid, these low to no income seniors would be unable to afford their health and long–term care costs, even with Medicare.

Speed to market: Culturally competent service providing new programs to our members and potential clients. Based on their needs we are expanding the services such as– care coordination, mental health counselling services and creative aging programs. The culturally competent case management service started back in September 2016 and from then on it is serving the South Asian community specifically low income and vulnerable population. It is very popular within south Asian community and the elders are living a stress free, happy and healthy lives.

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):

Yes. This Innovation implemented in September 2016 and impacted more than 150 people in our community directly and more than 3000 people are impacted indirectly. Our service has expanded to all around the five boroughs in New York City. In previous time, the service was only limited to the Senior center members, now we have clients from all around the New York City. We have more than 100 clients receiving this service and getting benefit from it. Also, we have more than 50 referral clients obtaining culturally competent case management service from us. 17 clients have started receiving cash assistance benefits, 32 reduced fare MetroCard, 4 access–a–ride, 8 SSI, 5 SSDI, more than 20 clients are receiving SNAP benefits. Referrals clients also benefited from the service we provide. We have applied housing for 24 clients and secured housing for 2 seniors at affordable housing cost. We have completed 22 citizenship application and 7 seniors obtained US citizenship. Providing literacy through our ESL and computer classes make their lives easier and which impacted positively in their health. Now the seniors are living independently, and they feel more affiliated with the community. Their social isolation level has decreased as they have regular walking and exercise groups. Also, in our senior centers they get the opportunity for some volunteer work. Group activities and creative aging program, group meals and outing has given them the opportunity to spend good times together. This has provided them a social network and help alleviates social isolation.

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