MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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

Trinity Alliance is a 106–year–old Settlement House located in the South End of Albany, with 10 locations in the inner–city neighborhoods of Albany, New York.

Our mission: To provide services to the community that will support and promote healthy families, adults and children......Our agency is dedicated to improving the neighborhood as a setting for family life, contributing to health and well–being, and promoting education and employment as a means of self–development.

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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).

Trinity Alliance of the Capital Region is a 107–year–old Settlement House with approximately 10 locations in the inner city neighborhoods of the city of Albany. Settlement Houses have a long history of public health involvement; the Henry Street Settlement House on the Lower East Side is the early 1900´s birthplace of the Visiting Nurses Association, founded when different immigrant groups exposed one another to their own diseases and a public health solution was required.

With its vast tentacles reaching into every upstream social determinant life domain within the city of Albany´s target neighborhoods, Trinity Alliance, along with its partners, is uniquely strategically positioned in the geographic and social epicenter of the challenge within the environs of the city of Albany, New York to accomplish a disruptive pro–social social determinant of health tipping point; converging a bulwark of upstream patient access enhancement, advocacy, credibility and trusted agency/cultural competence, community mobilization, policy influence and its amassed $4 million worth of programs, services and facilities in the social determinant space, and has leveraged millions of dollars of ´value–added´ large health care–related partnerships in the neighborhood.

Trinity Alliance of the Capital Region is currently operating its three Rapid Engagement and Advocacy for Community Health (REACH) health care access hubs under funding by the Alliance for Better Health PPS and to the Better Health for Northeast New York PPS´s to further their objective to provide closer–to–home rapid engagement and integrated care pathways addressing social determinants of health and patient engagement:

• Koinonia Primary Care, Inc. located at 553 Clinton Avenue in West Hill where Trinity Alliance Community Health Workers are referred patients from the practice facing a multiplicity of social determinant of health challenges.
• Trinity Alliance headquarters at 15 Trinity Place in the South End of Albany where Refugee Community Health Program is housed. Known as a Mecca of safety and information, access, systems navigation and advocacy, Quick Help utilizes Karen Burmese, Karenni Burmese and Arabic speaking Community Health Workers and translators, as well as a bevy of volunteers to address the needs of refugees resettled in the Capital Region.
• The Collaboratory, operated by the Albany College of Pharmacy and Health Sciences, at 3 Lincoln Square, a public housing tower on the South End´s Morton Avenue. The Collaboratory co–locates public health and pharmacy professors and students, along with Trinity Alliance Community Health Workers to combine forces to inform, engage, activate, advocate and educate customers to become personally empowered in their own healthcare.
• A fourth location co–located in our $6 million federally funded adult education/training Capital South Campus Center, within steps of 15 Trinity Place and the Collaboratory, is soon to open under the BHNNY PPS and will comprise a clinic–type setting featuring a nurse practitioner practice.

These targeted locations represent the most severely as–yet underserved population centers of the city of Albany and are at the crossroads of high concentrations of Medicaid–eligible attributed lives.

This intervention is already on the market, but Trinity is looking to further anchor this model in new hubs within our target neighborhoods. Acknowledging that value–based payment is on the horizon, promoting sustainability of this disruptive innovation is the next phase of this initiative. From the experiences of REACH, solidifying our community hubs as anchors to foster a workforce of deployable community health workers is the key to sustainability along with delivering positive population health outcomes. Within the three hubs that have been operating for approximately four months, REACH has been able to serve 350 unique individuals working to ensure, at minimum, each individual has health insurance, connections to primary care, and needed pharmacy supports.

REACH is embedded within the agency´s Center Based Services Division; there are two others including Community Based Network Services and Alternatives to Incarceration. Each division and each program within each division is geared to address the grassroots social conditions that lead to the disproportionate phenomenon of poorer health outcomes in urban settings and particularly communities of color.

REACH sits at the core of Trinity Alliance´s vast program and service continuum which addresses the Education; Social and Community Context; Health and Health Care; Neighborhood and Environment; and Economic Stability SDOH´s with a multiplicity of interlocking, complementary programs, like the hub of a wheel with a bi–directional service structure to the agency´s case management, family preservation, early childhood language development, violence prevention, in–jail and post–release services for returning citizens, cultural arts and health and wellness offerings, and the two largest, only–five–day–a–week–full–time food pantries in the city of Albany (to name just a few key Trinity Alliance elements). This work is achieved by our 105 culturally competent, trauma–informed staff members, many being credible messengers who have lived in these neighborhoods and overcome their own challenges.

Public health theory allows us to understand why individuals do or do not practice health–promoting behaviors while also paving the way to activate and mobilize an effective strategy. At its core, Trinity Alliance´s DSRIP–related program, Rapid Engagement and Advocacy for Community Health (REACH) views the community context through the lens of the Social Cognitive Theory. What was first the Social Learning Theory (SLT) in 1960 became the Social Cognitive Theory (SCT) in 1986 with the addition of ´self–efficacy´ as a construct. SCT differs from other behavior theories because it not only considers how individuals acquire behavior, but how that behavior is maintained over time. The theory takes into account a person´s past experiences, which factor into whether behavioral action will occur.

Adverse Childhood Experiences perceived and actual institutional racism, stigmatization, the medical model of ´doctor knows best´, lack of access, concentrated negative social determinants of health all conspire to stultify personal agency and collective efficacy.

REACH´s model employs a public health approach, used elsewhere within Trinity Alliance´s service structure, to engender both a disruptive personal and communal social determinant of health tipping point. In the ideal, personal and social efficacy go hand in hand and energize one another. For example, Trinity has been confronting what was perceived as the intractable challenge of urban gun violence thru a public health approach. Using credible messengers who lived in that lifestyle who have intimate relationships with the highest risk gunslingers at the social and geographic epicenter, the program redirects these ´infectors´ to more productive lifestyles, while also changing social norms such that gun violence is ´no longer acceptable here´. According to the NY State Division of Criminal Justice Services 2017 saw the lowest homicide rate since 1965.

"Social cohesion describes how residents think and feel about their neighborhood. Collective efficacy describes what residents are willing to do to improve their neighborhoods. Although social cohesion is the foundation of collective efficacy, at the core of collective efficacy are the willingness to intervene and the capacity for informal social control. In neighborhoods with collective efficacy, neighbors agree on what is acceptable behavior and reinforce it in each other." https://nij.gov/journals/277/Pages/collective–efficacy.aspx. Thus, Trinity and its grassroots partner, AVillage…Inc., galvanized the successful fight for the advent of the #100 public bus transportation line serving Arbor Hill, West Hill and the South End.

REACH seeks to provide a direct, tangible service to individual members of the community thru personal health care activation and empowerment while, more subtly but notably, collaborating with community partners to cultivate and mobilize the community in the context of social cohesion. Our partners, AVillage…, Inc (AVillage) and the Radix Ecological Sustainability Center (Radix) have been calling both the community at large and the healthcare system to action. With the advent of REACH, a new, accessible, deployable service exists in the South End, West Hill, and Arbor Hill neighborhoods of Albany for residents to utilize. AVillage, Radix, and Trinity have been heavily involved in activating, advocating and mobilizing the community to ensure that additional, complementary supports are brought to the table by larger healthcare systems and providers. An example of this is the attraction of the Albany College of Pharmacy and Health Sciences to the public housing space by the relationships created by AVillage, which, in turn, was born at Trinity Alliance some ten years ago.

Essentially, Trinity Alliance and partners seek to cultivate a culture of health. To create this culture, however, neighbors must talk to one another, trust one another, and perceive that their actions feed into the greater good of their community.

Public health research is bringing to light the benefits of green spaces to lowering all–cause mortality, cardiovascular health, improving mental health, and chronic diseases. Social isolation is another often–overlooked factor with large health implications, including increased risk of all diseases and cancer–mortality in particular.

Working closely with Radix Ecological Sustainability Center´s, under our DSRIP initiative, Trinity Alliance is developing neighborhood gardens on once–blighted vacant lots in the South End of Albany as a means and an end to achieving greater population health thru setting the social context. This initiative is powered by AVillage´s expertise in community organizing and mobilization, with results already being experienced in tangible population health–improving ways:

1. Land reclamation for public use as a neighborhood amenity;
2. Garden allocation to individuals and families engaging in mutual aid and support;
3. Production of fresh healthy produce;
4. Training a cadre of youth entrepreneurs in agriculture and stipend thru other funding sources;
5. Weekly fitness classes at the Capital South Campus Center;
6. Nutrition and healthy diet education;
7. The establishment of a Farmer´s Market (also leveraging other funding sources);
8. Citizen action geared to addressing the Albany County Land Bank in its policy development and implementation.

REACH´s expertise in systems navigation, community health work, and social determinant of health supports is bolstered by the ability of our indigenous Community Health Worker´s to point our customers toward the next step in building the social context for community level grassroots social determinant of health impact.

Return on Investment:

Trinity Alliance´s value proposition is that the agency brings well over $4 million of programs and services thru a multiplicity of contracts and credentials with the Office of Alcoholism and Substance Abuse Services, Office of Mental Health, State Education Department, Department of Health, Division of Criminal Justice Services, Office of People with Developmental Disabilities, Office of Children and Family Services, Albany County Department for Children Youth and Families, Albany County Sheriff, Albany County Youth Bureau, City of Albany, and other private sources including a large private foundation grant concerned with kidney health.

Generating collective efficacy on a large scale, while simultaneously working with community members one–on–one to address specific social health needs affects the community across the continuum of social determinants of health. Through leveraging high–impact technologies such as the local Regional Health Information Exchange (RHIO), data from Performing Provider Systems, and Trinity´s own Electronic Health Record, REACH is able to tailor its services specific to the health and wellness needs of consumers. Building trusting, long–term relationships with community members allows for REACH to proactively engage consumers in preventive health and wellness services, which in turn prevents over and underutilization of health services.

Trinity cannot do this alone; the hope is that policy and funding streams will someday become blended thru this application and what follows agencies. Fighting SDOH´s must have the freedom to address people´s challenges holistically.

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