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

Joanne Robinson

Managing Director, The Interfaith Nutrition Network, Inc. (The INN)

211 Fulton Avenue






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

The INN is a 501C3 not for profit which has been addressing hunger and homelessness on Long Island for the past 35 years.


To inspire all Long Islanders to transform lives by addressing hunger, homelessness and profound poverty through awareness, action and generosity.


The INN is a not–for–profit and volunteer–based organization that began as a single soup kitchen. Our holistic approach provides a broad variety of essential services to ease the hardships experienced by those challenged by hunger, homelessness and profound poverty. We advocate for the guests of The INN by partnering with them in a dignified and respectful manner to break the cycle of poverty.

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).


The proposed innovation project would address SDHs across a geographic area by harnessing the resources of the many existing food pantries at local churches, synagogues, mosques and community–based organizations, including volunteer resources generally available at these operations.

Project Description
Locations would be selected based on assessment of community need and accessibility to the target population of Medicaid recipients. Participating organizations must be able to provide pro bono space and at least 2–3 highly motivated volunteers. An existing IT infrastructure would also be an asset for entities being considered. Each "Gateway microsite" would be staffed with trained volunteers using a uniform training format and Case Management software database including connection to NowPow to provide the following services:

  • Food security: Food Pantry
  • Free Clothing (donated)
  • Health Insurance enrollment and referral to local federally qualified health centers and/or providers within the managed care plan; assistance with making appointments.
  • Assessment of eligibility for Care Coordination and referral to CMAs.
  • Transportation: Access to multi–pack Metro Cards and Uber rides as needed for special circumstances.
  • Transportation: Access to rides to critical medical, mental health, hospital admissions to be provided via designated vehicles driven by the volunteers (arranged in advance)
  • Assistance with application for obtaining ID documents
  • Income support: Assistance with application for government benefits (DSS and/or SSI)
  • Homelessness: Assessment of eligibility for Supportive Housing, Rapid Rehousing, local municipal housing and/or other designated housing programs and referral to the "regional supersite". See below for more detail on regional supersites.
  • Homelessness: Preparation and referral to DSS for shelter placement.
  • General Housing: assessment of suitability for shared housing with local landlords and assistance with advocacy for finding rooms to rent or share.
  • Employment: Assistance with access to computers, email, resume preparation and job boards; employment applications; coaching for job readiness and interview preparation.
  • Add on services: Microsites can also offer many additional services by partnering with local CBOs, for example, literacy/ESL legal services, enrichment activities/lectures, etc.

Each microsite would be teamed up with a "regional supersite" which would serve as the local hub for Coordinated Entry for Homeless Housing and could conduct SSD applications, mental health assessments and work on placement of qualified individuals and families on their priority lists. Regional supersites would also offer short term crisis accommodations for those who are currently ineligible for shelter placements. Supersites would also offer employment training, coaching, mentoring and placement.

Required Resources
Each microsite would require funds for transportation, application for ID documents (for those not yet eligible for Medicaid just require proper ID or who have lost their IDs), crisis needs such as rental arrears or moving expenses which would prevent homelessness and related expenses, computers/IT for both volunteers and program participants, Microsites should ideally have access to a refurbished vehicle for transporting program participants to critical appointments. Consideration must be given to items which are not funded by Medicaid such as dentures or a bicycle or motorized wheelchair which can mean the difference between being considered for employment and being financially challenged or homeless, loans or payments for rental arrears which can prevent homelessness. Transportation resources to travel for needs outside of health care must also be considered, for example, travel to a food pantry or to a job interview or housing opportunity. Transportation is one of the most critical unmet needs amongst this population which limits their mobility and successful accomplishment of meeting their basic needs.

The amount of funding and the use of such funding can also potentially make use of private donations available through the participating faith based and/or other CBOs.

Estimated startup expenses: IT infrastructure/internet access, case management software, pre–owned vehicle, office equipment/phones/privacy space and supplies. Locations would require some amount of waiting area space. $25 – 50,000 depending upon existing infrastructure available.

Ongoing annual expenses: $50–100,000 for program participant transportation and other incidental expenses plus operating expenses as needed, for example, software/IT. Larger programs would eventually require permanent salaried personnel.

Training and selection of volunteers and staff: Selection of personnel is CRITICAL since the program cannot be effective without the presence of staff/volunteers who ARE ABLE TO PROVIDE UNCONDITIONAL EMPATHY and who are adequately trained to provide services, including the use of Case Management software and Reporting Tools. A training team for each region which could offer advice/troubleshooting support would be an asset.

Regional Supersites: Experienced CBOs with existing resources could be utilized to provide training/support for the microsites, services for the profoundly homeless and additional services as needed such as skills training/workforce development to provide job training and enhanced employment services. These sites might require $100 – 200,000 per year for overseeing the regional program, including some form of quality monitoring.

Potential Return on Investment
Return on investment: In order for the low–income Medicaid population to access transportation, food, clothing, shelter, income support, employment and health/mental health services which are critical to maintain their health and well–being, they require locally accessible resources which can provide them with personal assistance which can meet their individual needs. With the use of Case Management software, it is possible to run standardized reports to document outcomes. Those who have transportation, food, clothing, housing, income support, access to health care and employment/employment training are far better equipped to experience improved health outcomes and reduced hospital/emergency room usage. Each microsite could potentially support up to 1,000 individuals annually. We would propose to have a study conducted for our existing program to quantify the potential return on investment. Health Home Supportive Housing programs have already proven to be cost–effective for those who are homeless and utilizing excessive health care resources.

Speed to Market
The proposed innovation could be conducted via a limited demonstration project over a specific geographic area with minimal startup time (6–9 months), provided there are willing participant organizations with adequate locations, physical space and volunteer resources and provided that there is support available for training, IT infrastructure development and i

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 project has been implemented at a single location at The INN´s Center for Transformative Change (CTC), which is adjacent to our Mary Brennan INN soup kitchen in Hempstead, which is Long Island´s largest soup kitchen. The CTC, which opened in January 2016, has served over 3,000 individuals to date. It is staffed by 2 full time staff members and a dedicated workforce consisting of over 30 trained volunteers, many of whom are retired professionals in the health and human services field. We utilize Case Management Software which enables us to record and report on services provided to each program participant. All 3,000 program participants have received access to meals, clothing, showers and use of computers. Over 150 have accessed ID documents, over 50 individuals have secured employment, over 400 guests have received assistance with their government benefits, nearly 20 profoundly homeless individuals have accessed either permanent supportive housing or housing with the local housing authority, at least 40 guests have been linked with Health Home Care Coordination. Hundreds have been enrolled in Medicaid and/or referred to Federally Qualified Health Centers. Thousands of Metro Cards have been distributed, and we have applied for and received grant funds for assistance with moving costs, dental fees, eye glasses and textbooks. For guests who require advocacy due to anxiety or literacy issues, we accompany them to government agencies and other critical appointments, often using our refurbished vehicle. We would welcome the opportunity to evaluate the impact that these services are having on associated health care costs for this population.

Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)

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