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

Frances ILozue M.D.

Rapha Family Wellness Center

3610 Main Street





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

Rapha Family Wellness Center is an affiliate of Rapha Family Medicine PC. From inception, our goal is to provide holistic wellness and lifestyle modification education to patients. Our founder Dr. Frances Ilozue is a primary care physician in Buffalo, NY. Many years ago, she saw the devastation that morbid obesity was having on her practice and she didn't have adequate resources to combat it. There are no good programs in the Buffalo area to refer these patients, so she decided to set up one. Our program focus is on Healthy Choices, Physical Activities, and Mental Counseling.

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).


The health impact of Social of Determinants of Health is more pronounced on Medicaid recipient when compared to other population. Leighton Ku, Julia Paradise, and Victoria Thompson (May 17, 2017) stated that “Adults in Medicaid have high rates of preventable and controllable conditions. Nearly one–third (30%) of non–elderly adult Medicaid beneficiaries report that they are in only fair or poor health – roughly double the percentage of low–income privately insured and uninsured adults who report fair or poor health. Medicaid adults also have significantly higher rates of chronic conditions and risky health behaviors that may be amenable to preventive care. One in 10 adult enrollees has a diagnosed mental illness; 7 in 10 are overweight or obese, and almost 1 in 3 smoke tobacco. “. It´s not realistic to achieve quality health outcome with this population without addressing the high incidence of obesity. We have developed a high– intensity intervention program that focuses on holistic wellness and lifestyle modifications, Rapha Wellness Program (RWP). RWP is tailored to target behaviors and environmental factors contributing to overweight. Holistic wellness is working on both body and mind to achieve success, happiness, health, and fulfillment in all areas of life. It usually translates to better quality healthcare outcomes for all patients. RWP is designed to help participants lose 10% of their body mass within 10 months. There are three major components in RWP:

  1. Healthy Choices
  2. Physical Activities
  3. Mental Health and Substance use Counseling

Healthy Choices: At the end of the program participants will have a thorough understanding of the relationship between what they eat, drink, and smoke, as well as the impact these actions, have on their health. They will learn effective strategies to help them make healthy choices.

Physical Activities: A Coach will help each participant to develop optimal physical exercises and routines that take each patient´s abilities into consideration. The coach will also provide motivation to stay on a regular exercise schedule, sustaining weight loss over a long period of time.

Mental Health Counseling: Evidence–based practice shows a strong correlation between mental health and obesity, a relationship we have become very familiar with through the eyes of our patients. During the counseling sessions, we address the foundational issues that make people gravitate toward poor healthy choices and work with them to develop healthier strategies to cope with life stressors.


Morbid obesity is a serious health condition characterized by an abnormally high body mass index (BMI). A person with obesity has a greater risk of developing diabetes, stroke, heart disease, high blood pressure, sleep apnea, asthma, arthritis and certain cancers among other health problems. In a Quarterly Journal of Health Care Practice & Risk Management Vol 20, Fall 2012 the author noted that obese patient tends to use more routine medical services than those who are not obese. This includes prescription drugs, ER visits, intensive care unit, hospitalizations, and they develop more infections and other postsurgical complications among other things.

Social determinants of health are huge issues in Medicaid population. Access to education, socioeconomic conditions, transportation, social support, and sources of quality food just to mention a few. Understanding the relationship between these conditions and their impacts on improving patient healthcare outcomes is very important. RWP articulated most of these challenges and has made provisions to mitigate some of them. The link between social determinants of health and obesity cannot be overstated but it can be overcome with proper interventions. Majority of the participant that will go through our program will lose 10% of their body mass within 10 months.

There are 30 different sessions within the program, each session is an hour long and participants are required to attend at least 3 sessions every month.

Healthy Choices: The Health Coach teaches many of the sessions, which are designed to help the participants make healthy choices and lifestyle modification. They are also required to check–up on the participant throughout the week. Depending on the session that´s being taught a dietician, clinician or culinary coach might be present to enhance the learning experience. Participants will learn how to set daily caloric intake goal for themselves and their family. They will learn to avoid the instances that get them to consume too many calories. There is a strong emphasis that healthy choices start by participants preparing most of their meals. Unfortunately, many people don´t know how to cook healthy meal thus the need to bring in a culinary/chef instructor to teach them the basics. Due to socioeconomic limitations, some participants are not able to afford fresh fruit and vegetables. Most of them also live in food deserts so access to quality food is poor. We help them learn how and where to find healthier food at affordable price. We also collaborate with other organization (farmers market, Co–ops and meal prep providers) to improve access to fresh produce.

Physical Activities: We have a state–of–the–art fitness center in our medical practice that makes it possible for a participant to lose the excess weight. We know that many of the Medicaid patients can´t afford a gym membership and even some that can have limited access. Our fitness trainer will customize a routine that will help each participant achieve their weight loss goal. Our fitness center is open six days a week and located in the same building where we teach all our classes. The effectiveness of our model is that all the services that we are utilizing for the program intervention are offered within the same facility.

Mental Health and Substance Use Counseling: Evidence–based practice shows a strong correlation between mental health and obesity. Tobacco, alcohol and substance abuse will also be address. Unfortunately, these participants cannot have a handle on their weight until those issues are addressed. Our counselors will screen the participants and offer appropriate group and/or individual sessions for those who will benefit from such intervention.

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):

We have been running RWP for about 2 years and about 70 patients have gone through the program.

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


Social and Community Context,

Health and Health Care

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