Poster Presenters - Community Based Organization Category

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Q1 Please provide your contact information below.


Title and Organization


Address 2



ZIP/Postal Code

Email Address

Phone Number

Marion Billings

MD, NYC H+H/Gouverneur

227 Madison St

3rd Floor

New York




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

New York City Health + Hospitals/Gotham Health Gouverneur is a large Diagnostic and Treatment facility affiliated with NYC Health and Hospitals. Through the Gotham FQHC we are an FQHC look–alike. The facility is located on the Lower East Side of Manhattan and is the largest freestanding provider of ambulatory healthcare in New York State, and for over 130 years has served a diverse and high needs population. The majority of our patients are on Medicaid, and Gouverneur strives to fulfill the overarching mission of NYC Health + Hospitals to serve as the safety–net health care system of New York City, committed to the health and well–being of all New Yorkers. At Gouverneur, the New York University School of Medicine serves as our academic affiliate. The Pediatric Department at Gouverneur provides primary care using the medical home model, and Gouverneur is certified as an NCQA level 3 medical home.

Q3 Please indicate which category your organization falls under.

Health Care Provider

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 Partnerships for Early Childhood Development (PECD) project is an innovated initiative because it addresses social determinants of health (SDOH) in a collaborative manner from several angles at once. Beginning in 2017, thanks to a small grant from the United Hospital Fund (UHF) and the New York Community Trust, we formed a formal partnership with four local Community–Based Organizations (CBOs) to better address social determinants of health among our youngest patients and their families. SDOH have an impact on the health of all New Yorkers, but the effect is especially profound in the early childhood period. Supporting families – and especially preventing the accumulation of toxic stress – allows them to optimally support the growth and development of their children through the pre–school years. This is a critical time in brain development; the health and developmental trajectory set in early childhood can persist into adulthood.

This partnership allowed us to better understand the services available at our neighboring organizations and helped us to develop relationships with key staff members in order to assist in, and streamline the process of effectively connecting patients and families to their wide array of programs.

In order to better identify SDOH needs among our youngest patients and their families, we began SDOH screening for families of patients aged 5 years and under in our practice. We developed a screening tool of well–validated questions to assess housing and food insecurity, financial and legal needs, childcare, educational or employment needs, as well as intimate partner violence. Child care emerged as the most common need, and a root cause of difficulty addressing other needs. Collaborating with our four community partners (Henry Street Settlement, Grand Street Settlement, University Settlement and Educational Alliance) we were able to define a process for supporting families through the complex process of accessing subsidized child care in New York.

The majority of our patients are insured through Medicaid and are living at or near the Federal Poverty Level. Children of low–income families are more likely to confront challenges in social determinants of health and are more likely to experience adverse childhood experiences that negatively impact early childhood development outcomes. Addressing these needs of New York State´s large Medicaid population was an integral aim of this project.

As we now move from the pilot stage towards universal screening of all patients in the first year of life or upon entry as a new patient to our practice, we realize that we must have a work flow that integrates all the screens we do at well child visits into our routine well–care process. In the next phase of this project we will transition our SDOH screening (along with other screening tools used in our practice) to a tablet–based format that will also be seamlessly integrated into an online social service resource directory and referral platform through NowPow. It will also allow us to expand our screening efforts as it streamlines the complex process in the community pediatric setting of getting the right screener, to the right patient, in the right language, at the correctly–timed well child care visit.

We are working with our Performing Provider System (PPS), OneCity Health, which has allowed for collaboration between SDOH screening efforts at other NYC Health + Hospital facilities and has provided a mechanism for likely future spread of our work throughout the system.

Our project is innovative, using an interdisciplinary process within the practice and with our community partners, which has resulted in a screening process that is simple and feasible to implement. In less than two years, we have planned and piloted the screening program, and after demonstrating feasibility we are prepared in the next year to expand towards universal screening. Over the next two years, we will transition and expand our screening program towards the tablet–based platform, while working to bring the program "to market" amongst other pediatric practices within our hospital system, in collaboration with OneCity Health.

Throughout the current and past phases of this project, our ongoing relationships and partnership with our four neighboring CBOs has enriched and informed our work, ensuring that it is truly a cross–disciplinary collaborative effort.

There is a large body of evidence pointing to the importance of this work. As outlined in in UHF´s 2016 report Seizing the Moment: Strengthening Children´s Primary Care in New York, there is great potential for long term improvement in health and mental health outcomes if pediatric well child care can effectively connect families to interventions that support families in the early childhood period. A steadily growing body of literature has shown that by supporting the social, economic and mental health needs of families of young children, one can foster optimal early childhood development which is so essential to the future academic, social and economic success of these young children as they grow into adulthood. As described 18 years ago in the National Research Council´s report Neurons to Neighborhoods (National Academy of Sciences, 2000), and continually supported by ongoing research, fostering positive early relationships and early life experiences (along with the complex contributions of genetics and environment) are essential to optimizing neurobiological outcomes.

In making these small investments in SDOH for families of young children, the return is vast and diverse. Our innovative approach through community partnerships and technology to improve SDOH screening and referrals in the pediatric setting will support these vulnerable families with young children to maximize their long–term health and development. By optimizing these early childhood developmental outcomes, the future economic success of the individual is enhanced, leading to a reduction in the potential future burden on a wide array of social service sectors, from health care, to education, criminal justice and beyond.

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):

2017–ongoing. 153 patients screened during pilot phase with 55 families referred for services. During second phase, plan is to screen 400 additional families and refer at approximately 80% of families with unmet needs.

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

Social and Community Context,

Health and Health Care,

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