MRT Innovations in Social Determinants of Health Initiative

• Document is also available in Portable Document Format (PDF)

Q1 Please provide your contact information below.

---

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

Family Service Association of Glens Falls, Inc. supports and assists children, families, and individuals during a crisis and guides them toward resolution, so they can function, be self–sufficient and stay intact.

---

---

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).

Family Service Association´s Innovation is our "Partners For Success" program which is blended with our overall "Strategies For Success"; a series of workshops that addresses nutrition, health, budgeting and finances and education. Two years ago, "Partners For Success" started as a grant–funded program designed to provide assistance and support to families living in generational or situational poverty and impacted by the social determinants of health such as education, social environment, healthcare, community contexts, and economic stability. It is still a viable and successful program today.

We talk with people every day and learn much about their families, their challenges, and what barriers they face in their daily journey of life. We designed the program with core features that included budgeting and saving money, relationship building with children´s schools, and developing communication skills within the family. Each one of these features was implemented based on records and stories shared by families and each feature grew and evolved as successes were recorded and challenges were noted.

The program now includes an organizational feature which encourages families to be involved in their daily and long term schedules with these simple tips: record who you talked to, record what is said, record dates of appointments, renewals and recertification of services, and keep important papers close. We provide tools so that insurance, SNAP, WIC, SSI/SSD and other program documents can be on hand when needed. This is a significant feature added to the program which has touched on the education, health, housing, and nutrition of our families.

"Partners For Success" is offered to families with children who visit our agency with a need for assistance. Often, the need is financial assistance for rent, emergency RX, or utilities and by offering this program, we work with the families to avoid another crisis. Because our program is designed as a one on one style interaction, we have found that tracking the successes and reworking some criteria based on challenges has helped develop short term strategic plans to assist families in looking ahead to their stability and their children´s future.

The Return on Investment is substantial. When we help a family avoid an eviction, we help the community at large by reducing court costs, eliminating moving expenses and probably most importantly, we help keep the children in their home school district and avoid the extra costs of transporting the children due to homelessness. When we help a family get health insurance through a navigator, not only do they get important coverage, but our program reminds them to keep track of renewal dates and provides folders to store all documentation. Keeping a family insured without a gap in insurance saves time and money for counties, agencies and families. Although most of our families are Medicaid or managed Medicaid eligible, keeping a family covered and on track with necessary medical appointments reduces many extra expenses including missed medical appointments, extra RX costs and emergency room visits. The scalability of our program is evident, because we first began with a goal of working with 5 families and now offer parts of "Partners For Success" to every family who visits us with a need. We have also expanded our network of collaborators who support our program. This program is feasible because each family gets the guidance and help that is appropriate for them. The evidence–based support for the innovation is in the casework. The "Thank you´ s" and warm notes of appreciation confirm this too. Confidential records are kept for each family.

The relevance to the Medicaid population is supported by the one on one work we do with the families. Our agency has been a CBO with the AHI PPS DSRIP program and we find that working directly with families can provide valuable information. For example, it has been very helpful in learning reasons for unexpected visits to the ER: they may not have minutes on their phone to call their own doctor, or may not have transportation during business hours, or may not be familiar with the Urgent Care centers in the area. We have spoken to many who do not even know what urgent care means. We can offer assistance to put minutes on a phone, bus tokens, and directions and hours of the local urgent care centers. We also add assurance that they will get appropriate and needed care outside the ER. Sometimes they need validation that their situation is serious. When a family is worried about their loved one, they want to get care in the way that they are best familiar with. The ER is it in many cases.

This program shows its relevance because it is centered on the Medicaid eligible population and keeps them in the conversation. We believe that the community at large may have plans or ideas on how to reduce poverty and the impacts of the social determinants of health, but if you do not have families living near at or near poverty engaged in the planning, the plans or ideas will not be successful. "Partners For Success" took months of planning to begin as a grant sponsored program, but evolved and grew after two full years of programming. We are seeing results that have impacted many in the community. By working one on one with families, we can guide them toward self–sufficiency and a future that can hold many possibilities for their children, including education, health literacy, and economic stability. Every family counts.

---

---

---

---