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

Caryl Sutterby

Coordinator Our Town Rocks

12 Main Street





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

The S2Ay Rural Health Network, formed in 1998, is a non–profit organization serving the Public Health Departments in Seneca, Schuyler, Steuben, Yates, Livingston, Chemung, Ontario and Wayne Counties. One of the S2AY Network Projects, funded by the Greater Rochester Health Foundation (GRHF), is the resident–driven, asset based Our Town Rocks (Raising Our Community, especially our Kids to be Strong) Neighborhood Health Improvement Initiative. The residents of the Barrington/Starkey/Dundee area have been working now for nearly 10 years to identify and connect the assets of their community, to make the changes they want to see happen, and to invest in their neighbors. Strategies and activities have been revised based on what has and has not worked in the past, activities that have been accomplished, formation of new and enhanced partnerships, and new ideas from area residents and organizations. Over the years, four focus areas have developed, Healthy Behaviors, Lifelong Learning, Social Health, and Community Development. The Healthy Behaviors focus area promotes physical activity, healthy eating, stress management and prevention of substance use, but also a new strategy for chronic disease self–management. Strategies for outreach to engage more residents in the OTR project, to connect residents with available services, and to identify gaps in services are also included in the Healthy Behaviors focus area. Approaches for improving Social Health include supporting and promoting annual events in the neighborhood, as well as facilitating the development of new social activities to bring adults, youth, and multiple generations together –– all intended to increase social capital in this neighborhood. Lifelong Learning includes approaches to enable area children to become proficient readers by Grade 3, to encourage learning throughout the lifespan, and to promote youth acquisition of literacy and job skills. The Community Development focus area has expanded to include several strategies: promotion of small business and job development; attraction of tourists/consumer by promotion of the area and beautification of the business district; development of both affordable housing and middle– income retirement housing; and promotion of use of the newly approved public transportation system.

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).

Our Town Rocks Healthy Behaviors Vision: Residents will be educated about and will engage in healthy personal behaviors, including self–management of chronic disease. All residents will be given the opportunity to be engaged in the Health Improvement Project. All residents, especially the vulnerable or underserved population, will have access to and will utilize needed programs and services.

  • The decision to engage in healthy behaviors is a personal one.
  • Behavior change is one of the most difficult things that we do as humans.
  • Unless motivated, many people have a hard time beginning and maintaining a healthy lifestyle.
  • Our Town Rocks supports and encourages residents to make healthy lifestyle choices by creating activities that promote healthy personal behaviors with the objective of making the choice to engage in a healthy lifestyle an easier one for the individual resident and family.
  • In support of making healthy lifestyle choices an easier one, OTR is proposing nine–month outcomes–based wellness program organized and offered in conjunction with the Dundee Central School Community Wellness Committee.
  • Activities throughout the year will include a Monthly Community Challenge coordinated with Dundee Central School staff and age appropriate student challenge, bio–metric testing, social and fitness activities and a Community Wellness Day.
  • Participation will be easy to understand and follow.
  • Monthly Challenges will be based on the 102 Challenges, collection of dynamic and inspiring challenges based on the science of how healthy habits are formed. Covering everything from fitness to nutrition, emotional wellness, financial wellness, and purpose, there´s something for everyone!
  • Unless motivated, many people have a hard time beginning and maintaining a healthy lifestyle but, just about everyone responds better to positive reinforcement so our incentive plan will be simple and painless
    • Health "gift cards", fitness equipment, travel and dining vouchers, raffled by–weekly to encourage engagement
    • $100 for completing qualifying smoking cessation program
    • Fitness membership provided for level of achievement
    • Celebration and recognition events monthly
    • Marketing: Today, more than ever, there are a lot of things competing for our attention. Our wellness program will need to be communicated in multiple ways and at multiple times to be effective including but not limited to:
    • Email, printed materials, newsletters, our website, posters, tabletop tents, meeting announcements, text messaging, Community Challenge Facebook page, calendars, Dundee Central School, spouses and significant others.
  • Process Evaluation:
    • Number of residents enrolled and participating.
    • Web site hits/Facebook participation
    • Observation or counts such as the number of residents walking at lunch.
    • Participant satisfaction via survey, focus groups, interviews, stakeholder survey, etc.
  • Outcome Evaluation: Outcome evaluation
    • Pre/Post surveys that measure change in attitude, knowledge and behaviors across time.
    • Aggregate screening measures such as blood pressure, cholesterol, body weight, BMI, etc. before and after specific campaign
  • Organizational Structure:
    • Community Challenge/Wellness Committee – Volunteers
    • Media Specialist – Paid – 5 hr/weekly
  • Collaborative Partners:
    • Dundee Central School Wellness Coordinator and Wellness Committee
    • Yates County Public Health
    • Finger Lakes Health
    • Finger Lakes Community Health
    • Pro–Action of Steuben and Yates Counties
    • United Healthcare
    • Yates County Community Center and Cultural Resources
      • BUDGET: $15,000
      • Supplies:
              102 Challenges Books residents who complete the challenge – 200 @ $20 = $4k
              Gift Cards/Fitness Equipment/Recognition items/Gym Membership – $1K
              Printed materials
              Media Specialist: – 5 hours weekly @ $20 – $4K
        Speakers/Providers @ Community Wellness Day – $1k
        Bio–Metric Screenings: $50 × 100 = $5k
        6 innovation criteria
    • ROI – Marketing figures allow for a successful campaign to deliver one half of one percent of the audience to product. Based on the Our Town Rocks service area population of 5000 residents, of which almost 20% are Mennonite families, that would result in delivering the campaign successfully to 200 residents. Using a budget figure of $15,000 results in a $75 investment per resident who completes the program.
    • Scalability – The 102 Challenges and other employment wellness program initiatives utilized for this project are adaptable to a variety of users or populations
    • Feasibility – The feasibility of the success this initiative will be the reach of the collaborative marketing campaign to our residents. Communication is shifting to public, more open forums. Which means less money spent on mailings, websites, and other marketing initiatives. According to the report, 9 ways social media is impacting the business of healthcare by Michelle McNickle, four characteristics of social media have altered the nature of interactions among people and organizations: user–generated content, community, rapid distribution, and open, two–way dialogue. "In the past, a company would connect with its customers via mail or a website, but today´s dialogue has shifted to open, public forums that reach many more individuals," read the report. "Early adopters of social media in the health sector are not waiting for customers to come to them." Ed Bennett, who oversees social media efforts at the University of Maryland Medical Center, agreed. "If you want to connect with people and be part of their community, you need to go where the community is," he said. 9 ways social media is impacting the business of healthcare by Michelle McNickle
    • Evidence based support for innovation – Adopting new, healthier habits will protect residents from serious health problems like obesity and diabetes. New habits, like healthy eating and regular physical activity, improves physical appearance and feelings of well–being, also help manage weight and provide more energy. Adopting habits that treat common psychological injuries when they occur, protects mental health and improve emotional resilience.
    • Relevance to the Medicaid population – The tables also show that 24.5% of the households in Our Town Rocks neighborhood, the towns of Barrington and Starkey and Village of Dundee, have no earned income, and a whopping 45.5% of the population lives at less than 200% of the federal poverty level. Sadly, 23.6% of Dundee neighborhood married–couple families in which the householder worked full time, year–round, still lived below 130% of the federal poverty level. A staggering 79.1% of married couple families with child under age 18 lived below 130% of the federal poverty level.
    • Speed to market – 4 to 6–month preparation to initial delivery

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