MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.


Title and Organization


Address 2



ZIP/Postal Code

Email Address

Phone Number

Emily Rogan

Project Manager, CBO Planning Grant, Health & Welfare

150 Broad Hollow Road

Suite 118





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

Established in 1947, the Health and Welfare Council of Long Island (HWCLI) is a regional, nonprofit umbrella organization for health and human service providers. We are dedicated to improving the lives of Long Island´s most vulnerable residents by responding to their needs through the promotion and development of public policies and direct services.

HWCLI serves the interests of poor and vulnerable people on Long Island by convening, representing, and supporting the organizations that serve them; and through:

  • Illuminating the issues that critically impact them
  • Organizing community and regional responses to their needs
  • Advocacy, research, and policy analysis
  • Providing services, information and education

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 is to use Health Information Technology to create a sector–wide Health and Human Services and Community Based Organization (CBO) shared platform to enable a longitudinal client record comparable to, and interoperable with, a medical longitudinal patient record. This shared platform will leverage work that is currently underway at HWCLI as part of the CBO Planning Grant award. That project proposes the creation of a system that better integrates CBO service delivery in communities from Elmont to Montauk. The proposed innovation will further enhance the scope of the CBO Planning grant project and enable alignment with DSRIP partners in our collective efforts to develop a more holistic patient record.

This innovation will create a population health analytics solution that will be shared between regional nonprofit health and human service organizations, local health systems including Northwell Health, and two Performing Provider Systems: Nassau Queens PPS and Suffolk Care Collaborative. The innovative and collaborative model will enable all CBO participants to utilize the same solution, avoid the costs of purchasing their own unique and separate vendor solutions, and allow the capture and sharing of data across the continuum of care. It will enable HWCLI members to more effectively provide vital services to their communities.

Through collaboration with Northwell Health, CBO members and potentially both Nassau and Suffolk Counties Departments of Health, HWCLI will gather requirements and design a more robust architecture to achieve this shared interoperable platform.

  1. The innovation may lead to a reduction in preventable ED use and avoidable readmissions by enhancing the sharing of data to improve coordination of care for individuals across CBOs and medical providers. Many of the factors that lead to avoidable hospital use are addressed by SDH providers, but these services are not well integrated into medical care systems or population health analytics platforms. A more efficient and effective closed–loop referral and data sharing mechanism between medical providers and CBOs may lead to a significant reduction in costs.
  2. The innovation is scalable across the Long Island region and beyond. Beginning with HWCLI as the umbrella organization for multiple CBOs, the innovation will expand its data sharing and population health analytics platform across all participating CBOs and establish connections with all medical facilities within the region that are willing to connect.
  3. The innovation is feasible since interoperability and data sharing is already taking place across health care providers using the Statewide Healthcare Information Network of New York (SHIN–NY). There are also several vendors that offer solutions aimed specifically at data contained by and utilized within CBO networks. Developing a shared platform for CBOs that consists of Application Programming Interfaces (APIs) will allow for interoperability across clinical and community–based service providers.
  4. There is considerable evidence to support non–medical health related social needs as critical factors to the overall health and well– being of an individual, including:
    • Research performed by the Robert Wood Johnson Foundation (RWJ) found that clinical care only accounts for 20% of health, while SDH account for 80% (socioeconomic 40%, Environmental 10% and Health Behaviors 30%).
    • Research performed by Promedica showed a return on investment by providing food insecure patients with a reliable food source. Patients who had positive screens for food insecurity and were provided with a "prescription" to the Promedica Food Farmacy had a 53% reduction in readmission rates, 3% decline in ED usage and 4% increase in primary care visits after screening.[1]
  5. The primary attribution for HWLCI and its participating CBOs is the low income, Medicaid and uninsured population.
  6. The speed to market is very important but it will depend on collaboration and funding opportunities. If this type of SDH Innovation is shown to improve Quality Metrics associated with DSRIP, VBP, and other risk contracting, speed to market will likely become a priority to Health Systems, MCOs, IPAs, and PPSs.

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,

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