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

Elizabeth Lynn

AVP, Grants & Research, Selfhelp Community Services, Inc.

520 Eighth Avenue

New York




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

Founded in 1936 by refugees from Western Europe, Selfhelp Community Services, Inc. (Selfhelp) is now one of New York City´s largest and most respected providers of services to older adults, with more than 20,000 clients served annually through 27 locations in four boroughs and Long Island.

Selfhelp blends social services and health care to provide a comprehensive network of community–based support for older adults. Programs include home care, in–home therapeutic care, skilled nursing, case management, comprehensive services for Holocaust survivors, affordable housing with services, chronic disease self–management and many other specialized programs that address economic stability, food, health supports, and community/social context. The organization´s overall goal is to provide older adults, and other vulnerable New Yorkers, with the necessary supports to remain in the community as they age.

Selfhelp´s mission: Selfhelp is a not–for–profit organization dedicated to maintaining the independence and dignity of seniors and at–risk populations through a spectrum of housing, home health care, and social services and will lead in applying new methods and technologies to address changing needs of its community. Selfhelp will continue to serve as the ‘last surviving relative´ to its historic constituency, victims of Nazi persecution.

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).

With funding from the NYS Nonprofit Infrastructure Capital Investment Program (NICIP) and Statewide Health Care Facility Transformation Program, Selfhelp is creating a predictive analytics system for the social determinants of health. To our knowledge, this is the first such system of its kind.

Predictive analytics are currently used in health care to identify patients´ risk of hospital admission, readmission and other adverse events. Selfhelp, through its daily operations, has collected a wealth of data on social determinants which can likewise be linked to adverse health outcomes. We are working with a software vendor, Clinlogica (, which has deep experience designing predictive analytics for health care and home care systems.

ROI: The outcomes tracked by Selfhelp´s system include MLTC CAG indicators and others that are vital in the provision of social care. We expect that the system will enhance the impact of value–based contracts by enabling us to not only track specified quality outcomes, but also provide interventions that will improve them.

Scalability: Selfhelp´s system is developed using a wealth of data from across a wide variety of programs serving older adults of diverse demographic backgrounds, languages and countries of origin. It can be scaled to engage new referrals from Managed Care Organizations and to include other evidence–based programs that impact the health of clients.

Feasibility: The project is eminently feasible. We are utilizing an existing software platform, evidence–based protocols, and the knowledge base of management staff with decades of experience to design the predictive analytics system.

Evidence–based support for innovation: Evidence–based assessments will be used to collect the data for the predictive analytics system. We will undertake a validation protocol as part of the design of the system.

Relevance to the Medicaid population: The system will focus on data and analytics that are most relevant to Selfhelp´s service population, which is primarily Medicaid–eligible. We are in discussion with several MLTCs about forming value–based contracting partnerships that utilize this data for their Medicaid clients.

Speed to market: The new system is under development and will be completed in 2019.

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):

The data warehouse and predictive analytics systems are currently under development. It will be implemented in 2019 and will affect all 20,000 of Selfhelp´s clients.

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