Community Based Organization Finalists

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Q1 Please provide your contact information below.


Title and Organization




ZIP/Postal Code

Email Address

Phone Number

Damara Gutnick, MD

Medical Director, Montefiore Hudson Valley Collaborative

3 Executive Blvd, 3rd Floor





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

Montefiore Health System is one of the largest providers of Medicaid and Medicare services in New York State, with 1.3 million Medicaid beneficiaries and 433,000 Medicare beneficiaries living in the four counties served by Montefiore and its affiliates. Montefiore provided over 2.5 million primary and specialty care visits to Medicaid recipients in 2016 alone. Leveraging the partnerships created through the Montefiore Hudson Valley Collaborative (MHVC) PPS, Montefiore has been able to expand their provider network throughout the seven Hudson Valley counties. MHVC is a partnership of more than 250 organizations representing a diverse group of stakeholders from hospitals, Federally Qualified Health Centers (FQHC) and Behavioral health organizations, to community–based organizations and public sector agencies that address the social determinants of health. Together, along with the Montefiore Health System, they aim to redesign the healthcare delivery system in the communities they serve, and collaboratively transform into an integrated system that seamlessly delivers the right care in the right place at the right time.

Montefiore has long been a leader in value–based payment arrangements, recognizing the need for transformational change in a healthcare delivery system serving a preponderance of government program beneficiaries for over two decades. With a limited ability to cross subsidize with commercial payments, moving up the premium stream became a financial imperative for Montefiore long before health care reform and the current push towards value. Risk–based arrangements have enabled Montefiore to capture more of the health care premium, keeping the dollars within the care delivery system and providing resources to enhance the delivery of patient care. Altogether, Montefiore manages the health of approximately 365,000 patient lives through Medicaid, Medicare and commercial risk arrangements.

Montefiore´s focus on collaborative partnerships is central to its implementation of a regional system of care and its success in population health management. Montefiore and our partner network facilities are located in economically challenged communities with a high prevalence of chronic illness and racial disparities in health outcomes and access to care. Montefiore successfully collaborates with other providers, government social service agencies, community–based organizations and local businesses to develop and implement health and wellness programs to address social determinants of health through more than 100 programs. Similarly, MHVC introduced the Innovation Fund in June of 2017. The Innovation Fund was designed to support the deployment of Innovative Pilot Projects (IPPs) across the Hudson Valley with a focus on delivering targeted interventions that address social determinants of health and improve clinical outcomes with an ability to demonstrate data driven Return on Investment (ROI). The Innovation Fund was designed as a formal RFP Process, where special focus was given to CBO partners to encourage creative programming that would link Hudson Valley patients to appropriate clinical services, including primary care services, and address their social determinants of health needs. Specifically, MHVC intended for this initiative to assist Tier 1 CBOs in supporting core services, including patient education, patient outreach and patient navigation.

Our mission is to heal, teach, discover and advance the health of the communities we serve, and as such, we are deeply committed to delivering high quality care while simultaneously addressing the many pressing social service needs of our patients.

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).

Please acknowledge this submission as Montefiore´s official application; please disregard our previously submitted version.

Montefiore is proposing using a 3–pronged, system–wide approach to dealing with the social determinants of health: 1) systematically and routinely conducting SDH screening; 2) using an evidence–based referral tool (NowPow) to link patients to CBO services; and 3) supporting CBOs by providing them with ROI training, coaching and tools including a ROI calculator.

  1. Relevance to the Medicaid Population: Incorporating routine SDH screening into practice: Much evidence has been gathered on the importance of identifying and addressing the social determinants of health, and yet few health systems have embedded evidence– informed screening tools as part of their practice. Montefiore has spent the last 2 years piloting and refining a screening tool that was informed by patients, staff and clinical leadership. We embedded the tool in our electronic medical record system, and the data fields have been normalized for incorporation into our enterprise data warehouse, allowing for population–level analytics (e.g., "What is the prevalence of financial insecurity among our patients with poorly controlled diabetes?" and "Where are the buildings that have the highest density of food–insecure patients?"). In addition to standardized implementation of SDH screening at our Bronx based sites, the Montefiore Hudson Valley Collaborative incentivized SDH screening at upwards of 50 partner organizations including multiple stakeholder types (hospitals, FQHCs, primary care, behavioral health, substance use, skilled nursing facilities and CBOs).
  2. Using an evidence–based referral tool, NowPow, to link patients to CBO services (1, 2, & 3): The second part of the 3–pronged approach is the use of a CBO referral tool. Importantly, we considered the need to align with other PPS networks across NYC and the adjoining regions to ensure scalability, CBO acceptance and speed to market. With several hundred CBOs live on NowPow as part of our multi– PPS project, we have begun creating a vibrant network of linked CBOs that are all using the same tool. This part of the innovation addresses the challenges of facilitating bidirectional referrals between health care entities and CBOs. Montefiore is deploying NowPow as the referral tool for its network and seeks to work with CBOs to build their workflows and technology to utilize it.
  3. Providing CBO Return on Investment (ROI) training, coaching and tools including an ROI Calculator: The third part of our 3–pronged approach recognizes that technology is not enough to create alignment between health care providers and CBOs, particularly for the purpose of payment. CBOs are challenged with being able to produce the data needed to demonstrate outcomes. They often do not understand the economics of health care utilization, and many struggle to demonstrate an ROI to health care entities. To address these gaps, MHVC created a series of CBO VBP training modules, and piloted coaching strategies and tools including an ROI calculator, to help guide difficult discussions related to demonstrating ROI of CBO interventions. Training modules our CBO partners have found to be exceptionally helpful are available on our Learner Central Site and include: "Moving from Government Work to Retail" and "Bringing Your Innovation to Market." We also provided targeted coaching to our Innovation Fund recipient partners to support and challenge them to develop sustainable business cases for their innovations. With Medicaid accounting for an ever–increasing portion of the state and federal budgets, it is imperative that we support appropriate funds transfers between health systems and CBOs for selected SDH services. To this end, we therefore created a "CBO ROI Calculator," which leverages real cost inputs to help CBOs quantify the impact they may have on reducing ED visits/IP admissions, and therefore costs. As part of this project, we are working with selected CBOs to help them enhance their business case using the ROI calculator, which we also hope to pressure–test using real–world experience for patients who have been screened and referred. This will help create more market–based information about the ROI of selected CBOs and their ability to impact quality and utilization.

Feasibility, Scalability & Speed to Market: We believe our 3–pronged approach forms the foundation upon which to build longstanding, co– management of patients between social service providers and health systems and have demonstrated feasibility in our work to date. We are happy to share our SDH screening tool with other entities, as well as to add other NowPow users to the workgroup we created, thereby allowing others to implement the initiative more quickly.


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):

In the Bronx and lower Westchester SDH–screening was implemented at 21–Montefiore Medical Group PC sites and a community pediatrics program. Accomplishments include: >20,000 patients screened, NowPow adaptation by >900 MHS staff and roll–out to several hundred CBOs as part of a 6–PPS collaborative. This year´s priority focus is on "closing the referral loop" to enable patient co–management between MHS providers and CBOs. Since January 2018, over 2,000 social service referrals were facilitated through the tool for MHS patients. In the Hudson Valley, MHVC´s contracting strategy incentivized adoption of SDH screening at upwards of 50 diverse stakeholder partner organizations. The CBO ROI calculator has been piloted with 2 Tier 1 CBOs in Rockland County (Meals on Wheels, TOUCH). We will continue to refine our tool and pilot its use as part of this effort. In addition, our CBO pilot with Meals on Wheels is in the process of becoming a VBP contract.

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