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

Katharine Burnett MSN, NP

Chief Strategy Officer, Planned Parenthood Mid-Hudson Valley

178 Church Street





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

2. Planned Parenthood Mid–Hudson Valley (PPMHV) is a reproductive health provider with five centers in four counties (Dutchess, Orange, Sullivan and Ulster) providing over 19,000 visits in 2017 and our mission is to "empower individuals to make independent, informed decisions about their sexual and reproductive lives by providing access to high quality, evidence–based and medically–sound health care and educational services."

PPMHV is a community leader involved in the places our patients live. Through education and outreach projects – sexual health courses, special events including ID cards and HIV testing, initiating and leading the Healthy Black and Latino Coalitions, and recently our MHVC Innovation Fund "Healthy Community Outreach Project" (HCOP) – PPMHV is recognized for our evidence–based health care and education programs as well as our sensitive and confidential provision of services in the health center or out in the community. Our outreach history includes a successful, targeted enhanced outreach program in Newburgh with a focus on Reproductive Health Care (RHC) in which we employ part time CHPs/Promoters to increase education, awareness and utilization of RHC services addressing health disparities. In our first year of programming, PPMHV realized a 500% increase in patient service utilization from African American and Latino populations.

Our CBO networking has ensured local Newburgh CBOs have a place to discuss their projects, learn about one another and other community initiatives, reduce duplication of services and identify gaps and additional needed programs. Our most recent outreach project funded by Montefiore Hudson Valley Coalition´s Innovation Fund is described below.

Q3 Please indicate which category your organization falls under.

Health Care Provider

Call for Social Determinants of Health Innovations

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).

4. As an active partner in DSRIP, Planned Parenthood Mid–Hudson Valley works closely with our Performing Provider Systems (PPSs) – Montefiore (MHVC) and Westchester Medical Center (CRHI). In August 2017, PPMHV applied for MHVC´s Innovation Fund grant and received $207,000 to implement the Healthy Community Outreach Project (HCOP) which will end as of September 30, 2018, but PPMHV hopes to find additional funding to ensure ongoing project activities allowing for ongoing community involvement and forthcoming replication. To date, HCOP has six partners including a housing authority complex (Newburgh Housing Authority – Mullins Apartments), CBOs (Newburgh Healthy Black and Latino Coalition), a national association (American Lung Association of the Northeast), pharmacies (Rite Aid and Ace Pharmacy in Newburgh), Orange County Health Department– Healthy Homes, St Luke´s Hospital, and a pediatric group with 8 centers (Children´s Medical Group). We also have three associates – The City of Newburgh, New Beginnings Church, and the local Newburgh YMCA.

Healthy People 2020 highlights the importance of addressing the social determinants of health by including social, economic and physical initiatives and programs that promotes good health for all. HCOP´s goal addresses conditions in the community environment that can have an influence on the Mullins´ resident´s health, specifically as pertains to Asthma an it´s triggers. Due to the complex, multifactorial nature of Social Determinants of Health, actions to address SDOH requires coordination and cooperation of multilevel partnerships across various sectors.

The benefits of our Innovation Project include the Social Determinants of Health and not only the reduction of asthma–caused ED visits and hospitalizations. If we agree "public good" is non–excludable and non–rivalrous, then this is the advantage of our MHVC Innovation Fund allowing the Mullins´ residents improved SDOH – feeling of belonging, neighborhood pride and improved safety, better health and access, and increased knowledge.

MHVC´s Innovation Fund Project: Healthy Community Outreach Project (HCOP) – opening proposal statement (August 2017) meets four of the SDOH categories – Education, Social and Community Context, Health and Healthcare, Neighborhood and Environment, and due to the ongoing success of HCOP, PPMHV hopes to change the acronym´s "C" from "Community" to "Communities".

Asthma, one of the leading respiratory conditions leading to frequent urgent care and emergency room visits, is often a result of an allergic reaction or hypersensitivity to certain items. Those items are referred to as "triggers". Although there is information available to those who have asthma resulting in difficulty breathing, they do not fully understand or are subjected to the triggers by others who are not aware of items triggering asthma. Having the correct medications, knowing and avoiding asthma triggers can successfully lead to a healthier patient – in this proposal, a healthier community!

Out of the 201 Mullins residents, 35 initial survey assessments based upon the Chicago Community Asthma Survey have been completed for the Innovation Fund project indicator measures. 21 survey participants Identified as either having asthma or as living with someone who has asthma. More specifically, 11 participants indicated they were the ones who have asthma. Additionally, four people who self–identified as having asthma also indicated another member of their household as asthmatic. 7 people indicated asthma complications have resulted in hospitalization (for themselves or the family member who they identified as having asthma). This may suggest the incidence of asthma is higher than we estimated in the original proposal to MHVC. The surveys also indicated limited trigger knowledge (71% believed a vaporizer is a good treatment for asthma and only 40% identified cockroaches as a trigger) and 62% thought asthma could be cured.

In addition to focusing on the Innovation Fund goals, the Healthy Community Outreach Project has addressed four out of the five Social Determinants of Health. During the summer, the fifth SDOH will be accomplished. The SDOHs workshops and activities are a result of the Innovation Fund project´s staff and advisory board recommendations and desires for enrichment opportunities for the Mullins community.

The impact has been enormous with civic leaders contributing, health plans participating, agencies and CBOs requesting to be affiliated, but most importantly residents not only partaking but proudly having ownership of these new endeavors.

  1. Education –
    1. Increase health knowledge – asthma, smoking, nutrition, medication (Innovation Fund)
      • 5 Asthma training workshops conducted by the America Lung Association of the Northeast and the Orange County Department of Health for the project staff, residents and Newburgh´s Black and Latino Coalition. The trainings have included triggers, asthma and children, asthma and nutrition, asthma and exercise.
    2. Alternative food sources – farming/nutrition
      • Weekly Farmers´ Market to start in July
      • 5 Mullins residents involved in the community Victory Garden
    3. Mullins Asthma Newsletters – monthly publication for residents with asthma information/education, project and residents´ highlights, monthly calendar of events
  2. Social and Community Context
    1. Increase participation in the Mullins Housing Authority complex
      • Mullins Advisory Board
      • Residents
      • Outside Community representation
      • Mullins clean–up day
    2. Networking in the community and The City of Newburgh
      • Launch celebration, open house, meet and greet
      • Presented at the City of Newburgh City Council work session informing the council of residents´ needs for safety and stress reduction
      • stop signs to ensure safety for residence children getting on and off school buses
      • city clean–up in wooded area across from the Mullins apartment
      • Networking opportunities – St Luke´s Hospital Asthma Coalition, Newburgh Police Department, and Faith–Based Organizations Orange County Department of Health Healthy Neighborhood Program
      • Advised the DOH – the Mullins Apartment had been dropped by mistake from the Newburgh census – since re–established
    3. Improving residency and neighborhood through projects
      • Family Day at the Mullins with health plan representatives (United Health Care and MVP) and local medical providers (Children ´s Medical Group, NYS Department Center for Environmental Health) and Power Against Tobacco conducting a program "Reality Check – for Teens"
    4. Involving adolescents in projects
      • Newburgh Housing Authority/HCOP summer basketball team
      • 4 Poetry Circle sessions for teens to develop poetry about asthma triggers
  3. Health and Healthcare
    1. Reduced asthma triggers through education and environmental assessments
      • 23 Environmental assessments of residences to date with ongoing assessments to be conducted
    2. Smoke–free apartment complex
      • 70 Units/65 Families of Mullins will go SMOKE–FREE on July 1, 2018.
      • American Lung Association of the Northeast conduct their smoking cessation program in mid–June and July 2018 Smoking residents aided with medication through NYS´s Quit–Line and POW´R Against Tobacco, and PPMHV
    3. Medication compliance/Asthma Action Plan
      • Education program with pharmacist scheduled for July 2018
    4. Asthma screening event
      • Scheduled for July 2018 with WMC specialist
      • Children and Asthma – education presentation with American Lung and the Children´s Medical Group – August 2018
  4. Neighborhood and Environment
    1. HUD – Newburgh Housing Authority – Mullins Apartments
    2. Improved environmental conditions – clean–up, additional stop sign for safety
    3. Urban Gardeners at the Mullins with a community vegetable garden
  5. Economic Stability
    1. Developing an adult literacy to increase computer skills knowledge

When creating a roadmap, it is important to acknowledge and ensure all initial required criteria are met. PPMHV recognizes our responsibility for continued compliance of our MHVC Innovation Fund indicators while acknowledging the SDOH needs and desires of the community as identified by the Advisory Board and residents.

Return on Investment –

  • Increase knowledge of triggers to reduce unnecessary asthma flare–ups and ED visits with possible hospital admissions
  • Smoking cessation to reduce short and long–term ED/hospital admissions and ongoing treatment costs for numerous acute and chronic illnesses associated with smoking
  • Healthier life styles with nutrition knowledge and acquired gardening skills
  • Focused teens involved in suitable social/educational activities rather than alternatives Scalability –
  • Housing Authority Apartments
  • Train–the–trainer programs for replication into other Newburgh Housing Authority complexes
  • Ability to duplicate in other cities with initial project parameters Feasibility –
  • Successful ongoing program which can be replicated
    • Train–the–trainer asthma program; American Lung Certified Asthma Curricula
  • Future Advisory Board meetings will address how to ensure the projects in place are continued at the Mullins o Mullins Advisory Board members to create program to share with other Housing Authorities

Evidence–based –

  • Creating opportunities for people to interact and work on projects of shared values is critically important in a society where there are frequent changes in population. These ongoing changes can also present challenges, including different types of discrimination or conflicts of values, and can lead to some people becoming isolated. Giving people the opportunity to interact and make a contribution to their community can also build bridges, dispel myths and develop a shared sense of belonging. (Community Cohesion in Action 2010; Qualifications and Curriculum Development Agency. Gov.UK)
  • According to Community Guide (USA.Gov Dec 2017), studies demonstrate most people in the United States, including children and adolescents, do not eat enough fruits and vegetables (CDC, 2017; CDC, 2014). Children who regularly eat vegetables are more likely to develop healthy eating habits as adults (Maynard et al., 2006). Studies have shown that regular exposure to fruits and vegetables increases consumption among children (Patrick et al., 2005; Koch et al., 2006), and gardening interventions have been found to increase children´s preferences for, and willingness to try, new fruits and vegetables (Robinson–O´Brien et al., 2009).
  • Tobacco use is responsible for more than 430,000 deaths each year and is the largest cause of preventable morbidity and mortality in the United States (CDC). The Centers for Disease Control and Prevention (CDC) recommends programs that combine and coordinate community–based interventions that focus on the following areas.
    1. Preventing initiation of tobacco use among youth and young adults
    2. Promoting quitting among adults and youth
    3. Eliminating exposure to secondhand smoke, and
    4. Identifying and eliminating tobacco–related disparities among population groups

Relevance to the Medicaid Population

  • HUD housing with residents participating in Medicaid or Medicaid products
  • DSRIP Montefiore Hudson Valley Collaborative (PPS) Innovation Fund site

Speed to Market

  • Newburgh project includes resident train–the–trainer programs which have started to ensure the asthma trigger project is replicated in the Mullins and in other Newburgh Housing Authorities.
  • Poughkeepsie project – in process to begin application to CRHI/Westchester Medical Center. WMC has great presence in Poughkeepsie with the acquisition of St Francis Hospital. MidHudson Regional Hospital is an important community leader meeting the health needs of the citizens of Poughkeepsie. PPMHV hopes to receive Innovation Funding to duplicate our Newburgh Healthy Community Outreach Project with the desire to rename our project to Healthy Communitie"S" Outreach Project.

Why the NYS Innovation SDOH Award? PPMHV knows the SDOH aspects of our project can be replicated by HUD complexes. We have seen an incredible impact, led by residents, with community leaders and CBO partners coming together to discuss ways to provide desired opportunities for improvement and making it happen. Additional funding for project managers, staff and events will be needed. Where does this money come from? As the SDOH are addressed and health improves, health care cost goes down. PPMHV applauds NYS for investing in health and not in health care costs.

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):

5. Social determinants of health are conditions in the environments in which people are born, live, learn work and play that affect a wide range of health, functioning and quality–of–life outcomes and risks. Resources that enhance quality of life can have a significant influence on the community health outcomes. With the consultation of the Mullins Advisory board, consisting of residents, key community stakeholders, i.e. city council members and former residents. Thus far, HCOP had over 500 attendees participate in the Innovation Implementations from March – June 2018. To address the SDOH categories in the Mullins Public Housing, HCOP conducted the following Innovation Fund and Public Good workshops/ presentations/activities:

  1. Education – 135 attendees
    1. Asthma Peer–to–Peer Certification Training – Provider – ALA of the Northeast
    2. POW´R Against Tobacco – Reality Check – AMA of the Northeast Youth Initiative Adult Literacy Training – Provider– Best Resources – July 2018
    3. Mother´s Day Arts & Craft Program – HCOP Staff
    4. Saturday Youth Activities – Kazi Oliver Drumming
    5. Newburgh Armory Unity Center – Youth Saturday Enrichment Program at the Mullins –July 2018
    6. Mullins Teen Poetry Workshop
  2. Health and Healthcare –15 attendees
    1. Access to Healthcare via the NY State of Health – Provider – Planned Parenthood –July 2018
    2. What is Asthma? Provider– ALA of the Northeast
    3. Asthma and Nutrition – Provider –Orange County Department of Health Community Health
    4. Asthma & Environmental Triggers – Provider –Orange County Department of Health Community Health
    5. Asthma and Children – Provider – Children´s Medical Group – August 2018
    6. Food and Asthma – Provider – Honey Locust Farm House – August 2018
  3. Social and Community Context – 286 attendees
    1. Civic Participation
      1. HCOP Program Launch
      2. HCOP Office Ribbon Cutting
      3. HCOP Resident Meet & Greet
      4. The City of Newburgh Annual Memorial Day March
      5. Newburgh Healthy Black & Latino Coalition
      6. Anti– Poverty Taskforce/Empire State Poverty Reduction Initiative (ESPRI)
      7. HCOP presentation at The City of Newburgh, City Council – March 21st Work Session 1. HCOP Manager requested City´s assistance in cleaning wooded area across the street from development. Request completed early June. Manager requested stop signs on Walsh Road (in progress)
      8. Family Day at The Mullins – Community Event 1. Vendors included; United Healthcare, Children´s Medical Group, Orange County Health Department Community Health Outreach, Westchester Medical Center Health Network, MVP, NYS Department of Health Center for Environmental Health – Hudson River Fish Advisory Outreach
      9. YMCA Camp Robbins for Youth Development, For Health Living, For Social Responsibility
      10. New Beginnings Church
  4. Neighborhood and Environment – 78 participants
    1. May 16th Newburgh Tornado Outage Outreach – HCOP Staff
    2. Access to Healthy Foods
      1. Healthy Orange Farmers Market, Sponsored by House of Refuge Church in Partnership with the Orange County Department of Health (Community Outreach Division); Cornell Cooperative Extension of Orange County – July 2018
      2. Mullins Urban Victory Gardeners Club Kick–Off
      3. Mullins Urban Victory Gardeners Club – Providers – Newburgh Urban Farm & Food Initiative; Honey Locust Farm House
    3. Orange County Healthy Neighborhoods Program provides prevention environment health services.
  5. Economic Stability
    1. Job fair – Department of Labor – July/August 2018
    2. Adult Literacy Training – Provider– Best Resources – July 2018

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