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

Chris Norwood

Health People Executive Director

552 Southern Blvd





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

The mission of Health People, a peer educator–based organization, is to empower and train residents of communities overwhelmed by chronic disease and AIDS to become leaders and educators in effectively preventing ill health, hospitalizations and unnecessary death. Our main goal is to assure that New York´s community with the worst health has the information, tools and training to start rebuilding its own health itself.

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).

New York City has some 14,843 school–age children residing in family shelters every month.

The asthma rate of children living in shelters is extremely high––from 30% to 50% in studied shelters versus 10.5% overall for NYS Medicaid/CHIP insured youth. While targeted asthma education for individual families has been shown to be effective in reducing serious asthma attacks/emergency room visits, the daunting numbers of children in homeless shelters––and daunting shelter conditions––– require an innovative response.

Health People proposes to implement a peer–facilitated asthma attack prevention program directly in homeless shelters. This program will provide multi–session evidence–based asthma attack prevention education to parents––and older children themselves–––in small groups of 10 to 12.

The trained peers will also assess parents´ and children´s health care linkages; for those not connected to or in regular care with a primary care physician for the parent and pediatrician for the child, the peers will provide linkage and navigation, including escort for totally disconnected parents.

For children in pediatric care, the peers will obtain release of information permission from the parents to keep the pediatrician updated on the parents´ participation in the education program––as they will for parents/children newly connected to care. The peers will also recommend that if children continue to have severe attacks, the physician refer parents to one of the CHW programs now making home visits for more intensive management and support. After the group education course is complete, the peers will continue to visit the same shelters and hold an ongoing monthly support group.

Social Determinants
The direct social determinant we address is health and health care, including access to primary care/trusted providers and health illiteracy; also very important, this intervention brings social cohesion––through group support––to parents who are widely depressed and disconnected.

Evaluation Criteria:
Return: Group education reduces costs even as it provides a key strategy for reaching high need and disconnected families impacted by childhood asthma. Scalability and Feasibility: Health People has shown constant ability to scale peer programs and provide multi– session evidence–based health education at a range of community sites. For example, its community diabetes self–care education program under DSRIP, which also includes a multi–session group course, will have engaged almost 900 participants in two years.

Evidence Base: This innovative program is built on Health People´s in–depth experience constantly demonstrating the ability of peers to engage depressed and disconnected populations as well as on the literature. A classic study at Kaiser Permanente showed that parents who learned asthma care in an interactive group did significantly better at helping their children control asthma than parents who received the same information didactically; recent research shows low–income parents are more receptive to children´s interventions other parents recommend than those just referred clinically.

Speed to Market: Health People, based on experience, projects rapid implementation for this initiative, after a short start–up for peer training and site development. However, we must underscore that it needs support/funding from the major MCOs/ACOs and/or PPSs in a targeted area so that virtually all children with asthma in a targeted shelter can participate!

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

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