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

Rushka Tcholakova

Senior VP of Community Impact, United Way of the Greater Capital Region

One United Way




(518) 640–2370

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

The mission of United Way of the Greater Capital Region is to improve lives and advance the common good in the Capital Region by mobilizing the caring power of donors, volunteers, and community partners to give, volunteer, and advocate for people in need. Our United Way invests in the building blocks for a good life. These are the ability to meet basic needs, the opportunity to receive an education that leads to a job that pays well, a stable income that provides long–term financial security, and resources to gain and maintain good health.

United Way of the Greater Capital Region brings donors, organizations and experts together to advance initiatives that tackle problems at their root. This increases our capacity to make lasting improvements in the social conditions that affect us all and prevents problems from occurring in the first place. United Way also strengthens our community through grant making to more than 80 carefully–reviewed programs that demonstrate the capacity to achieve measurable change in people´s lives and social conditions. United Way monitors each funded program to make sure donated dollars are used efficiently and effectively.

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).

In New York State, Medicaid patients frequently visit emergency departments. Many hospitals and health care providers have responded by building new and promoting existing community–based primary care sites and urgent care clinics.

In spite of this, costly emergency department utilization remains very high in the state. In one study, 33% of the emergency department patients had more than three chronic conditions, and Medicaid patients were 55.2% of the 20,351 total study population. These findings are consistent with other studies; Medicaid patients are more likely to use the emergency department than non–Medicaid patients. (

Research suggests that more than 70% of health outcomes are attributable to the social and environmental factors that patients face outside of the clinic or hospital. (Health Leads, Social Needs Screening Toolkit,screening– That´s why United Way of the Greater Capital Region´s 2–1–1 program is so critical. 2–1–1 is a free service that´s available 24/7/365. Our 2–1–1 program is available in 12 counties to 1.2 million people. One call connects residents to a trained operator who evaluates the caller´s needs, accesses a database of more than 5,000 local services and connects them to the best possible solution with information and referrals to appropriate and conveniently located services. 2–1–1 operators also provide access to three–way calls with interpreters in 200 languages as needed. A newly refreshed website – – offers 24/7 access to easy–to–navigate online searches for community resources.

United Way of the Greater Capital Region, the Alliance for Better Health, and Unite Us have partnered to pilot Healthy Together, where providers call 2–1–1 on behalf of Medicaid clients to access services that can keep them out of the hospital, emergency room, and other expensive health, mental health and social services. Healthy Together is a DSRIP, or Medicaid redesign, project. This innovative project has the potential to be offered directly in hospitals and emergency rooms in the future.

Here are some of the requests that recent callers have made to United Way of the Greater Capital Region´s 2–1–1 program:
"I had to leave my apartment with my 8–year–old son and I need emergency housing assistance."
"I really need some counseling on legal matters."
"I have a daughter, she has an addiction problem with painkillers, and I´m trying to find some help for her." "I need to find out my local pantry number."

Callers get referrals to numerous local community services, including (but not limited to):

  • Food Assistance
  • Housing Assistance and Shelters
  • Domestic Violence
  • Heating & Utilities Help
  • Abuse Prevention
  • Elder Care
  • Mental Health Services
  • Transportation
  • Disaster Services
  • Employment & Income
  • Health Care
  • Parenting Help
  • Child Care
  • Legal Services
  • Addiction Services
  • Education

2–1–1 provides a solid return on investment and has developed the infrastructure to handle more calls. With an annual investment of $254,626, United Way of the Greater Capital Region´s 2–1–1 program handled 15,908 calls and 1,138 web visits during the past year. 2– 1– 1 provides callers access to a variety of services that help to keep them out of the hospital, emergency room, and other expensive health, mental health, and social services.

Additional funding to market 2–1–1 will help to increase call volume and program impact. Unfortunately, United Way of the Greater Capital Region´s budget for 2–1–1 marketing is very limited – approximately $9,000 per year. United Way is seeking additional marketing funding to increase the number of people who call 2–1–1 for help and the number of calls. About half of the people who call 2–1–1 once call again.

Here is how the Healthy Together pilot project works. The Alliance for Better Health is reaching out to organizations to participate in the HIPAA compliant Unite Us platform, so they can contact 2–1–1 for referrals on behalf of their Medicaid clients. This will also help 2–1–1 to update its database of services, therefore providing better value for all callers. 85% of the services listed in United Way of the Greater Capital Region´s 2–1–1 database were updated during the past year.

Clients who receive services through Healthy Together consent to creating a HIPAA compliant electronic record in the 2–1–1/Unite Us platform. Trained operators contact the appropriate service providers, ask them to contact the caller, and assign the case to the provider. The more urgent the call, the faster the 2–1–1 operator follows up with providers to ensure the client receives services. The provider contacts the caller, provides services and enters notes into the 2–1–1/Unite Us platform. Information about the caller and services received is available to all 2–1–1 operators, to help them better assist callers and clients in the future.

Launched in April 2018, so far 50 clients have received referrals and services through this pilot project. The goal is to test the integrated service for 12 months with 60 providers. In the future the Alliance for Better Health will consider offering this service in local hospital systems.

Healthy Together is a great fit with United Way of the Greater Capital Region´s future plans for even greater 2–1–1 innovation. Our 2–1–1 program is starting to evolve our 2–1–1 program beyond 24/7 Information and Referral (I&R). Our long–term goal is transformation towards a Community Information Exchange (CIE) model, offered by 2–1–1 San Diego. We believe that in the future, CIE will be replicable within the 2–1–1 New York network.

CIE is a HIPPA compliant, collaborative, multi–dimensional technology platform with actionable client–level data. When clients opt into the CIE system, their record can be shared among partner organizations with their history and life events. This saves clients from having to retell their story to every service provider. CIE empowers providers to connect clients to other medical and social services that will help improve client outcomes. CIE can act as a virtual case management system with alerts. When a trigger event occurs, such as an ambulance being called, every providing organization for that individual is notified. If another service is needed, a referral can be made on behalf of the client. It also provides a more seamless way to integrate services into the CIE system, which provides greater value to callers and clients.

United Way of Greater Capital Region is working on technological innovations to support 2–1–1, including texting, online chat, enhanced online services to help discharge planners and community–based professionals refer clients to appropriate local services, and partnering with other providers to verify and include additional services in the 2–1–1 database.

We also are exploring the possibility of piloting a project to place 2–1–1 operators in a local hospital emergency room to make follow up calls for Medicaid patients. The goal is to ensure a smooth continuum of care and access to food, medication, transportation, and other services, so that patients don´t return to the emergency room.

United Way of the Greater Capital Region´s 2–1–1 covers 12 counties and 1.2 million people: Albany, Columbia, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington. It also serves United Way of the Greater Capital Region´s service area, plus four others: United Way of Fulton County, United Way of Columbia and Greene Counties, United Way of Montgomery County, and Tri–County United Way.

Nationally, 2–1–1 is a partnership between the Alliance of Information & Referral Systems (AIRS), 211US, United Way Worldwide and organizations and programs that manage and deliver 2–1–1 services at state and local levels. Nearly all 50 states Washington DC and Puerto Rico receive 2–1–1 services. United Way 2–1–1 Northeast Region is a member of 2–1–1 New York, which set standards for call center performance and provision of 24/7 2–1–1 services. This supports replication our proposed initiative in New York State and throughout the nation.

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):

50 to date

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

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