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

Shauna Porteus

Community Services Librarian at the Yonkers Public Library

1 Larkin Center





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

Yonkers Public Library (YPL) was chartered in 1893 and has three branches throughout the city. Situated just outside New York City metropolitan area, YPL is the largest library system in Westchester County and serves an estimated 195,000 residents. Our mission is to change lives every day by becoming an integral part of the community and offering a "one stop" shop of services to assist people. These services include information referrals, early childhood literacy workshops, vocational training, health and wellness programs, English language classes and literacy for adults, teen programming, and technology classes. In 2017, the library visits exceeded 947,000, a 7% increase from 2016, making us one of the busiest destinations in Yonkers. More than 750,000 items were checked out, 3,146 programs were held for adults, teens and youth, and library staff answered 282,955 reference questions.

YPL has become an integral part of the community by offering a "one–stop" shop of services to assist people, including:

  • Onsite high school equivalency (TASC/GED) tutoring four times/week
  • Weekly vocational services that include job searching assistance, resume building, and interview techniques.
  • Partnership with Literacy Solutions, offices are located in our Riverfront Library, to provide English language classes for adults.
  • In 2016, library staff answered 282,955 information requests ranging from crisis intervention to a book recommendation.
  • Strong focus on hiring bilingual staff to better communicate with our patron base.
  • 3,146 programs offered to adults, teens, and children ranging from job training, TASC tutoring, afterschool homework help, early literacy workshops, health and wellness programs, and technology classes were offered in 2016, bringing in 67,000 attendees.
  • Free access to wifi and 148 public internet terminals available for residents and non–residents.

YPL has strong collaborations that ensure services and programs are diverse, including partnerships with public school district, universities, childcare centers, literacy providers, municipalities, small businesses, and nonprofit organizations. These partnerships and our multiuse facility allow us to play a vital role 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).

For many Yonkers residents, particularly vulnerable and underserved populations, basic physical and mental health and everyday living needs go unaddressed due to lack of resources, information, and limited access points. However, libraries have a long tradition of being viewed as a welcoming, safe space for individuals and often act as the de facto community health center. On a daily basis, public librarians at Yonkers Public Library (YPL) receive information requests for crisis intervention services ranging in topics from homelessness and hunger, domestic violence, substance abuse, health and mental health needs, to housing instability. Connecting people with the information is a core service at YPL; however, our ability to provide valuable information and equitable service is challenged when patrons require a level of service that is outside our area of expertise.

Montefiore Hudson Valley Collaborative (MHVC) provided financial support and hands–on technical assistance to pilot an evidence–based intervention to address this gap. YPL partnered with Cluster, a Yonkers–based community services organization, to connect case managers with patrons in a one–on–one consultation at the library. Using a person–centered care model, two case managers work two days a week at YPL´s Riverfront Library and Grinton I. Will Branch meeting with clients to provide a needs assessment of the individual´s physical and mental health needs, service use, housing situation, societal participation, and quality of life. This collaboration expands the public´s access to health and social service information, provides much–needed individual help to vulnerable populations, and reinforces the value of YPL as a community resource. YPL is the first library in Westchester County and among only a handful in the state to provide onsite case management.

Cluster uses a community–collaborative model to make referrals within a large network of agencies. This, along with developing a strong relationship with the client, ensures that individuals don´t fall through the cracks or get lost in the system. It also allows the "domino" effect to happen where multiple needs can be addressed at once using a broad range of resources and partners.

Additionally, in an effort to better understand the health needs and gaps of our library patrons we are also collaborating with MHVC and the Einstein School of Medicine to collect Patient Reported Outcomes (PROs) and information on health and SDH needs directly from library patrons at the Yonkers Public library.

ROI, Scalability & Speed to Market: Similar programs have been successfully piloted and spread in other libraries. On Cape Cod, for example, the Provincetown Community Resource Navigator Program was so successful after 1 year that it was spread to additional towns. (1,2,3) MHVC is providing the technical assistance needed to develop a sustainable business model for this project. The program can be spread and adapted using a passive (low financial impact) or active model (increased financial impact).

Passive model with relatively low financial impact:

  • Forge strong partnerships with local community–based organizations
  • Seek case management services on a volunteer basis using either social service agency or students at local college, if applicable.
  • Put community referral information in the library for patron consumption

Active model with increased financial impact:

  • Hire/contract onsite case managers
  • Forge strong partnerships with local community–based organizations
  • Continuous staff training
  • Administration/leadership commitment
  • Local government support
  • Marketing and communication plan identifying target population
  • Data collection software
  • Assess available public and/or private space within library
  • Program funds



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 program officially launched January 22, 2018. Two case managers are onsite twice a week at the Riverfront and Will Library. Between Jan. 22 – April 13, 2018, the case managers worked with 79 library patrons, while librarians answered 159 reference questions either about the case managers and/or the program. Primary reasons for visits were: housing (48%); employment services (6%); public assistance benefits (15%); mental illness (8%); meditation (8%); substance abuse (2%); housing conflict (2%); and misc. (3%). Secondary reasons for visits were: public assistance benefits (56%); mental illness (24%); mediation (8%); substance abuse (4%); housing (4%); and misc (4%). Housing was further broken into subcategories (affordable housing, homeless, imminent risk of homelessness, and senior housing). Within the housing category, clients sought help in the following areas: affordable housing (55%); homeless (23%); imminent risk of homelessness (11%); and senior housing (11%).

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