MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.


Title and Organization


Address 2



ZIP/Postal Code

Email Address

Phone Number

Tim Kelly

Chief Strategy Officer, AdvantageCare Physicians (partner of EmblemHealth)

55 Water Street

12th Floor

New York




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

As one of the country´s largest non–profit health plans, EmblemHealth is the local leader in delivering personalized and high–quality, affordable care for working families in New York City and Long Island. Our mission is simple – to create healthier futures for our customers and communities.

EmblemHealth´s approach to care starts with aligning the health system toward patients´ health needs, rather than forcing patients to navigate a disconnected system on their own. We have developed unique partnerships and programs to accomplish these goals:

  • We work closely with Advantage Care Physicians of New York (ACPNY), one of the largest medical groups in the New York City area, serving approximately 500,000 patients with 36 offices across Manhattan, Brooklyn, Queens, Staten Island, and Long Island and employing a diverse workforce of 2,100 people including 400 clinicians in the state. Our strength and reach as a health plan and a physician practice allows EmblemHealth to play a leadership role in delivering population–based, efficient, and high–quality care.
  • We have also established ten Neighborhood Care facilities located in low–income and ethnically diverse areas throughout New York City with several others to open this year. These facilities are staffed by counselors who work with local residents to help them navigate the health care and social service systems. In many cases, Neighborhood Care is located within an ACPNY office, which allows us to quickly identify and address our enrollees´ medical and social service needs.

As the health needs of New Yorkers become increasingly more diverse and complex, EmblemHealth is expanding its reach through first–in–class, ground–breaking collaborations to ensure New Yorkers always have a trusted partner for critical health and social services close to home. In particular, our robust value–based arrangement with ACPNY is helping us to develop new models where care delivery is community–based and engaging, instead of detached and one–size–fits–all. Currently, all ACPNY HMO patients are covered by a VBP contract, and most recently, we expanded coverage for 40,000 NYS Medicaid EmblemHealth members into a Risk Sharing Program of a NYS Level–2 Value Based Arrangement.

ACPNY providers work in tandem with EmblemHealth to identify the top specialists in the larger EmblemHealth network so that our primary care providers are always able to refer patients to the highest quality providers in their own neighborhoods. With a network of providers who are engaged in value–based care, our patients and members are assured of high–value care across the enterprise.

EmblemHealth and ACPNY offer primary and specialty care, behavioral health and social services to New Yorkers at the neighborhood level. This unique partnership powers new innovation programs, encourages payors and providers to be more efficient and delivers value back to customers and New York taxpayers. Together, EmblemHealth and ACPNY employ nearly 4,000 people in New York State. We believe these partnerships allow EmblemHealth to address social determinants in ways that will improve the lives of the individuals we serve.

Work is also underway on our latest partnership with Cityblock, a new Alphabet–backed firm focused on integrating real–time technology systems to support care delivery for complex, vulnerable patients, including "dual–eligible" beneficiaries. Cityblock and EmblemHealth will launch local care teams in Crown Heights, including behavioral health specialists, data analysts, community health partners and primary care clinicians, to serve these patients directly. While EmblemHealth has oriented its care services around addressing those broader social determinants of health, the latest partnership with Cityblock reflects our commitment to bringing high–quality, coordinated care to patients who otherwise may have struggled to access the health system in the first place.

Q3 Please indicate which category your organization falls under.

Health Care Provider,

Other (please describe below: 150 character maximum):

Health Care Provider (AdvantageCare Physicians) Health Plan (EmblemHealth)

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).

At EmblemHealth, our model is driven by continuous innovation. Our approach to care is unlike any other offered by health plan–provider partnerships in New York City. ACPNY and EmblemHealth have a wide and deep footprint – we operate in many working–class neighborhoods across greater New York City. Our sites often provide the only non–Federally Qualified Health Center non–hospital– affiliated care in the neighborhood, and our presence tethers patients to a larger network of care – specialists, other clinical partners and community–based organizations all working in partnership.

The core focus of our efforts is to align individuals with social workers at Neighborhood Care facilities located in the same building as their medical care professionals. This model allows us to quickly and conveniently address our enrollees’ social service needs. For example:

  • We built a robust patient–centered care management program encompassing all our patients but designed to engage the most vulnerable. When a patient visits the ER, becomes hospitalized or has not been seen for primary care within the year, our providers and care teams have rapid response efforts to outreach them, bring them in for care, and connect them with social services. Behavioral health is also integrated into our screening and care coordination workflows so that we can be sure we are addressing a patient’s complete needs.
  • ACPNY and Neighborhood Care staff share data and work in tandem to provide customized care. For example, our medical offices use PCMH–approved screening tools to identify patients needing additional support to address social determinants of care. Providers and care teams then work with care navigators and social workers at Neighborhood Care to help patients address their needs. These activities may include assisting them in identifying and enrolling in federal and state programs including the Supplemental Nutrition Assistance Program (SNAP) or helping them to find someone to repair their heating units on a cold day. We also participate in the National Diabetes Prevention Program: our providers use CDC–approved screening methodology to identify patients with prediabetes, and these patients are able to access free nutrition classes, exercise classes, lifestyle coaching, and group support sessions at Neighborhood Care. These programs are successful because we have served New Yorkers for decades and work hard to build trust: we’ve implemented specific staff training around social determinants of health workflows to ensure that we always approach patients with respect and sensitivity.
  • ACPNY and Neighborhood Care staff at each office rely on a localized network of community resources to address social determinants of care. Our relationships are deep: our medical staff and Social Work Case Managers not only refer patients to SNAP, MTA, Access–A– Ride, Department of Education programs, and other citywide service organizations, we regularly host Community–Based Organizations at our sites and co–develop workshops. At our Empire location in Crown Heights, for example, we have formed a lasting relationship with CAMBA to help housing–insecure patients find or keep apartments and access legal aid.
  • Neighborhood Care facilities often function as ad hoc community centers where local residents meet up to take a class and check in with their neighbors. These are spaces where all members of the community can go for preventive care, nutrition, fitness, ESL and health literacy classes, or find assistance with accessing critical health services around the city – all free of charge. We invite community– based organizations to use these spaces at no cost for activities that increase awareness of healthy habits and encourage more use of primary care.
  • Our Neighborhood Care counselors are also experienced in linking patients with behavioral health services, including suicide prevention and other critical needs. Our locations in low–income neighborhoods bring care to the doorsteps of many Medicaid and dual–eligible patients and connect these patients to larger health “hubs” that offer primary, specialty, and social services.
  • Where so much of medical care targeting the underserved address only the most dire cases, we also understand the importance of keeping patients healthy in the first place. Robust data exchange and reporting infrastructure between EmblemHealth and ACPNY enables us to identify patients who simply have not engaged medical care in a while and invite them in for a checkup.

These areas of innovation allow us to deliver best–in–class care efficiently, a track record that continues to drive our plans to further expand into medical deserts. We are building more primary care micro–sites or “spokes” in underserved neighborhoods, starting with Queens and the Bronx. These micro–sites will bring care to the doorsteps of many Medicaid and dual–eligible patients and connect these patients to larger health “hubs” that offer a full complement of primary, specialty, social and ancillary health services. These hubs offer episodic care services for finite periods of time when people require more specialized services or have a specific health problem, while the primary care micro–sites ensures care is engaging and continuous for patients.

Most importantly for the purposes of this application, these programs are available now, and we are also broadening them to new neighborhoods. We are already in neighborhoods where many Medicaid beneficiaries live. One does not need to be an EmblemHealth enrollee to take advantage of them. We are expanding the number of ACPNY and Neighborhood Care facilities because these partnerships work. They are a crucial component of EmblemHealth’s return to financial stability and are helping us fulfill our mission to create healthier futures for the individuals and communities we serve.

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):

Ten EmblemHeatlh Neighborhood Care locations, including eight co–located with ACPNY practice locations, implemented and providing clinical, social and community–based services described in Section 2. Demonstrated positive impact on health outcomes and patient experience, quality and overall cost of care for populations served. Social determinants of health screening tools implemented at all 36 ACPNY practice locations, achieving NCQA PCMH Level–3 standards with high provider and care team adoption rates. Care management and other community–based programming described in Section 2 is personalized at each location based on patient and community health needs. Our Diabetes Prevention Program received full recognition from CDC in 2016 for quality, evidenced–based program design. Demonstrated positive impact on health outcomes and patient experience, quality and overall cost of care for populations served in recent years. Approximately 200,000 New Yorkers across ACPNY practice locations are covered by an EmblemHealth VBP contract.

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