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

Linda Wright

Divisional Social Services Director, Empire State Division, The Salvation Army

200 Twin Oaks Drive

PO Box 148





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

The Salvation Army (TSA) has been supporting our most vulnerable citizens in 5,000 communities across the United State for over 130 years. Nationally, nearly 30 million Americans receive assistance from The Salvation Army each year through a broad array of programs and services. Nearly 200,000 individuals are served annually in the 48 upstate counties that make up the Empire State Division of the Salvation Army in NYS. Services range from providing food for the hungry, relief for disaster victims, assistance for the disabled, counseling to victims of violence, outreach to the elderly and ill, shelter to the homeless and prevention opportunities for children living in poverty. The mission of the Salvation Army is to meet human needs without discrimination.

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).

According to the United States Department of Agriculture (USDA) 12.3 percent or 15.6 million households in the United States were food insecure in 2016. In New York, that number is slightly higher at 12.5%. Meaning 12.5% of our friends and neighbors lack access to enough nutritional food for an active and healthy lifestyle for all members of the household. With greater limitations being put on the federal SNAP program, this number is only growing. On an average, SNAP provides less than $4 a day for food. Think about our frail seniors on limited incomes having toast and tea for breakfast or single moms having peanut butter on bread in the kitchen while they provide their children with a balanced meal in the other room or the homeless vulnerable man who is unsure where his next meal is coming from. Although Department of Health grants to the Food Banks and other emergency food providers across New York have remained steady since the recession, individuals and families turning to the Emergency Food pantries are no longer using it for short term emergency purposes. Clients of The Salvation Army (TSA) food pantries across our communities are coming back month after month for food. People are hungry in a state that is an agricultural leader.

Across our Division (48 counties in central and upstate New York) we have been brainstorming how we could create an environment in which serving people who are hungry, could be done differently. We know how scary change can be – how many times a week do you hear someone make reference to "this is the way we always do it?" The Salvation Army is proposing to be a change agent – to disrupt the system. Move beyond thinking about nourishing our communities on an emergency basis once a month but recognizing essential (ongoing) food assistance – is a fundamental component of decreasing emergency room visits of people with chronic illnesses and decreasing overall healthcare expenditures. Let´s create the Essential Food Network.

New York State Department of Health works diligently with Food Banks across the state to encourage healthy options are available at the food pantries they provide food to. However, the majority of Food Banks provide very little service directly to clients. The Salvation Army is seeking help to transform every TSA food pantry across central and upstate New York into an ideal Essential Food Network for addressing food security (a critical social determinant of health), increase rates of primary care visits and well child visits for the chronically poor, and decrease emergency department visits.

This can be accomplished through:

  • Space configuration of our current pantries to highlight and better promote fresh fruits and vegetables, lean protein and dairy (in partnership with the Food Banks) and capacity to serve clients as often as they need food (through a prescription for food model) through a choice approach that provides complimentary fruit for children and speaks to the value of eating meals as a family.
  • Health care professionals and dietitians on site for screenings, follow up and meal planning assistance (in partnership with MCOs and/or FQHC). Providing nutritional guidance or "shopping education" that promotes meal planning and cost–effective cooking at home.
  • Community Heath Outreach Workers providing a "Pathway of Hope" on site (provided by The Salvation Army) – will help screen for other needs as they relate to social determinants of health (housing, job/income related, substance abuse, etc.) as a part of the food shopping experience
  • Nutritional education classes and food demonstrations (in partnership with Cornell Co–Operative Extension)
  • PAM Screens; insurance enrollment, referral/handoff to primary care physician
  • Linkage to Children and Adult Health Homes care management
  • Identifying a University interested in health outcomes research on pantry clients and overall savings to healthcare expenditures
  • Help with resume building, job skills and soft skills development (in partnership with community work force development organization). Individuals participating in the Essential Food Network will be engaged in onsite job training right at the food network location, including retail skills training.

Specifically, this innovation will address the following:

ROI – The overall Return on Investment of this project could be infinite. Food insecurity is estimated to cost United States health care system $77 billion dollars annually. For example, we know that clients engaged in SNAP (Supplemental Nutrition Assistance Program) participation have approximately $1400 less in annual healthcare expenditures. Many times, pantries are serving working poor clients who make a few dollars more than SNAP eligibility guidelines. Helping expand the nutritious essential food options for those who don´t qualify for SNAP and even those who do, in combination with other social determinants of health linkages could have critical implications on public health outcomes and costs.

Scalability – The Salvation Army in partnership with New York State Food Banks is scalable. We propose working with DOH to identify the highest need region with greatest opportunities for partnerships and linkages as they relate to other social detriments of health and true impact. From here we can roll this model out to (1) other regions across upstate, central and northern New York; (2) through the TSA and Food Bank networks we could replicate within New York City; and (3) this essential food network could transform the way we think about food insecurity across the United States as TSA Empire State Division and Food Banks use their national parent organizations to promote the Essential Food Network concept to other Salvation Army´s and Food Banks across the nation.

Feasibility–The Essential Food Network is absolutely feasible. We are all working within our schema to address the direct needs of food insecurity or the results of proper nutrition. The interest, the funding, the overall climate is right to shift the paradigm on how we think about serving the needs of those who are food insecure. We are not creating a new program – we are linking existing programs for a complete maximization of current resources community by community and region by region.

Evidence based support –There are several studies that routinely demonstrate that nutrition programs focused on low income Americans, especially ones with complex medical problems can provide a great return on investment with regard to improved health for the people and decrease of emergency visits, ambulance calls and in some situations, hospital admissions. TSA would like to integrate our Pathway of Hope program into the Essential Food Network as well. As a national TSA model, we know that 83% of clients have shown increased income, achieving financial stability, 88% of clients employed, with an average of $5,900 increase in family income, 82% achieved stable housing, 78% accomplished educational/training goals, and 71% address transportation barriers. A Loyola University Chicago School of Social Work study evaluating the Pathway of Home program model found that having a wide array of regional resources and network allows for quality referrals and greater impact – further demonstrating the importance of the Essential Food Network. This same study looked at the importance of hope in the Pathway of Hope program model for our Salvation Army programs in the mid–west. Research completed by Philip Hong, Ph.D. demonstrated that when clients increase levels of hope in their times of adversity, challenge and failure resulting from social and economic exclusion within the workforce they are more likely to achieve sustainable success. Hong also notes that overcoming barriers with hope is a necessary condition to achieve Economic Self Sufficiency.

Relevance to the Medicaid population–The Essential Food Network is in total alignment of Medicaid population serving those who have a limited income (the food insecure population). Research shows that those who are food insecure have a 30% increased risk of mortality long–term, cannot properly manage their chronic diabetes because they don´t have the funds to acquire healthy and tasty food options to make a complete lifestyle change. Food and proper nutrition are essential to the breast cancer patient receiving chemotherapy or someone recovering from a surgery caused by a fall and a broken bone. Furthermore, it is an opportunity to link the essential network clients to other Medicaid eligible populations such as Adult Health Homes or Children´s Health Homes care management or WIC (an underutilized resource for women and children).

Speed to market – The Salvation Army propose 3–6 months to assess readiness of the community, develop and formalize partnerships and identify additional resources. As we stated the climate for this type of project is prime and we feel there are many foundations and corporations in conjunction with NYS DOH that would be interested in supporting this project. After the 3–6–month preparation time we feel the Essential Food Network could be launched immediately. Public private partnerships are key to this nutrition intervention. Let´s move beyond the charitable food system acting as a critical stop–gap but recognize the Essential Food Network as an investment in improving the public health of New Yorkers.

Food is THE critical factor for so many vulnerable populations. The Essential Food Network could be adjusted to serve a single population group such as our fragile elderly or children, those food insecure individuals with chronic disease or homeless individuals non–compliant with medical preventative maintenance. Overall, why not treat food insecurity like you treat anything else – write a prescription for food at The Essential Food Network.

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.)

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