Social Determinants of Health and Community Based Organizations

Social Determinants of Health (SDH) are defined as the conditions in which people are born, live, grow, work, and age. These conditions can affect a wide range of health risks and outcomes. The five key domains of social determinants of health (SDH) include: economic stability, education, social and community context, health and health care, and, neighborhood and built environment. Integrating health and human services to address SDH can have a significant impact on health outcomes. Under Value Based Payment (VBP), VBP Contractors aim to realize savings while achieving quality outcomes by addressing SDH conditions that drive healthcare cost and poor health outcomes.

The purpose of this page is to act as a resource of information for health systems and community–based organizations in relation to the VBP Roadmap requirements. Starting January 1 2018, all VBP Level 2 and 3 arrangements MUST implement, at a minimum, one Social Determinants of Health (SDH) intervention and contract with at least one Tier 1 community based organization (CBO). Please feel free to email all questions about this requirement to the SDH team at To find out more about the Bureau of Social Determinants of Health, please click here.

New Initiatives

Call for Social Determinants of Health Innovations: Bureau of Social Determinants of Health, launched a new initiative to identify innovative ideas that effectively address the Social Determinants of Health (SDH) for Medicaid members across New York State. The intent of this initiative was to solicit input from interested parties across the state and around the country. Submitted innovations were reviewed by a team of healthcare experts identified by DOH. The top 9 innovations were highlighted at a DOH sponsored SDH Innovations Summit in NYC.

Medicaid Redesign Team Supportive Housing: Since 2012, NYS DOH has invested into capital projects, rental subsidy and services targeted to high–utilizers of Medicaid. This link has new and existing supportive housing initiatives funded under MRT including rental subsidies, capital and services for high–utilizers of Medicaid.

SDH/CBO Tool Kit

  • Prevention Agenda Dashboard – Available on NYS Department of Health webpage. Contains sub–county level indicators for Social Determinants of Health.
  • Food Insecurity – Feed American, estimated data on food insecurity across NYS counties.
  • Community Health Needs Assessment – Community Health Needs Assessment Toolkit enables users to identify vulnerable population in specific regions and/or run an indicator report on the health needs of community members.

SDH and CBO Engagement Reports and News Articles:

What Montefiore´s 300% ROI from social determinants investments means for the future of other hospitals, Susan Morse, Healthcare Finance (July 5, 2018)

Greater New York Hospital Association (GNYHA), in collaboration with The New York Academy of Medicine (The Academy) published a report on Partnerships Between New York City HealthCare Institutions and Community Based Organizations. The report discusses successes and challenges related to CBO integration into the healthcare space. Full report can be accessed HERE

Given the impact that social factors have on health status and expenditures, and the shift toward value–based payment models that reward providers based on outcomes, health care organizations (HCO) and community–based organizations (CBO) across the country are increasingly working together to address patients’ social needs. The full brief is available on  Center for Health Care Strategies, Inc.

Value Based Payment (VBP) Resource Library

Effective January 1 2018, all new and existing Value Based Payment (VBP) Level 2 and 3 arrangements must include at least one social determinants of health (SDH) intervention and at least one contract with a Tier 1 Community Based Organization (CBO). This requirement applies to Managed Care Organizations (MCO), Managed Long Term Care (MLTC), and PACE plans with a Level 2 or 3 VBP arrangement. Health plans and VBP contractors have the flexibility to decide on the type of intervention that they implement. The guideline recommend the SDH selection be based on information including but not limited to, SDH screenings of individual members, member health goals, the impact of SDH on their health outcomes, as well as an assessment of community needs and resources.

  • This document is the social determinant of health interventions that have been approved by the Department of Health.


October 30, 2018 – Lessons Learned from the Field
  • This webinar was a joint presentation from a Tier 1 community based organization, Northern Manhattan Improvement Corporation and a VBP contractor, SOMOS Community Care, that have entered into a VBP contract for a Social Determinants of Health intervention. Hear from both sides on barriers, successes and best practices. VBP Lessons Learned: SDH Contracting Webinar Slides (PDF)
September 26, 2018 – SDH Innovations Summit

The Department of Health recently launched a first of its kind initiative to identify innovative solutions that can effectively address social determinants of health (SDH) for Medicaid members across New York State. The 'Call for SDH Innovations' solicited creative ways to improve outcomes through SDH from community–based organizations, healthcare providers and plans, and private sector technology firms. For more information please click here.

August 3, 2018 – Social Determinants of Health and Value Based Payment for MCOs and MLTC Plans
  • This webinar is for Managed Care Organizations (MCOs) and Managed Long Term Care (MLTC) plans. Topic areas covered will include: facts and myths of VBP; examples of Social Determinants of Health interventions; contracting arrangement; key contracting terms; and reporting. (PDF)
July 11, 2018 – Value Based Payment for Community Based Organizations Webinar
  • This webinar is for community based organizations that are considering entering or in the process of entering a contract with a VBP Contractor. Topic areas include, clarifying common VBP misconceptions, how to get involved in VBP, explaining what to consider when creating a value proposition, and key items to have in contracts. VBP CBO Webinar Slides (PDF)


Delivery System Reform Incentive Payment (DSRIP) Program

DSRIP Performing Provider Systems (PPS)

Population Health Improvement Program

Medicaid Managed Care Organization Plan Directory

Managed Long-Term Care Plan Directory

VBP University

DRSIP Value Based Payment Resource Library

HEDIS Measures

First 1000 Days on Medicaid Proposals

Provider Contract Guidelines for Article 44 MCOs, IPAs, and ACOs

Community Based Organization (CBO) Planning Grantees– Please contact grantees for available administrative/ support services for CBOs.

Arthur Ashe Institute for Urban Health

Health and Welfare Council of Long Island – Long Island

Health and Welfare Council of Long Island – Hudson Valley

Healthy Community Alliance – Rest of State
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