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

Yinan Lan

Attending Physician at Bellevue Hospital Center

462 First Avenue

Desk 2D

New York




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

The Bellevue Safety Net program aims to provide well coordinated care to the most vulnerable patients at Bellevue Hospital Center and New York City. This program recognize that our most vulnerable population are people who are unstably housed while dealing with substance use, mental health, and/or medical problems. This group of vulnerable patients rarely received regular primary or preventive care, but often use the emergency department or hospital admission when conditions become irreparable or life–threatening. We aim to provide well coordinated, regularly–available, flexible medical care and social support for this group of highly vulnerable people.

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).

Currently, one of the most vulnerable people in NYC are people who are unstably housed while dealing with substance use, mental health, and medical problems. This group of people often cycle through various public institution including public shelters, hospital emergency room, hospital admissions, and /or the prison/jail systems. They often receive very fragmented care at various locations. Health and Hospital internal data showed that for people who are seen most frequently at the Bellevue Hospital emergency department and inpatient admission, 70% are dealing with substance use disorder, followed by mental health problems, followed by various chronic medical problems. At least 58% is identified as homeless (checked by frequent zip code changes, which is likely an underestimate). Less than 12% of those identified as homeless had access to regular primary care, which means that they often present to the emergency room or hospital admission when medical/mental problems have become irreparable or life–threatening.

The Bellevue Safety Net program is made up of 4 internal medicine physicians and supportive staffs including a case manager and a social worker. Our medical and social providers are able to provide direct medical, substance, social support treatment in addition to connecting patients efficiently to services that are already available within and outside of Bellevue Hospital Center.

Our Patients are identified by the level of utilization of the emergency room and inpatient hospitalization, then further selected for housing instability and medical complexities. Interested patients may also be referred from outside outreach programs. Our medical and social providers aim to maintain a flexible clinic model that will allow the same team of providers to see patients in the clinic, emergency department, inpatient/hospitalized, or outside of the hospital. This aims to lower the access barrier of a traditional public hospital clinic. (Traditionally, a patient must call or come in person to complete hospital registration, receive an assigned new patient appointment, present promptly on the appointment date/time, and wait an average of 3–4 months in order to have another follow–up appointment if schedule available.) The traditional clinic model present multiple barriers for a vulnerable patient who may already be overwhelmed with housing, medical, mental, and substance use issues.

  • ROI: Prior studies done at Bellevue and at other locations have shown that coordinated intervention has the ability to decrease inappropriate utilization of the emergency room and hospital admission significantly. We also expect that this program will increase reimbursement as many people lacking social and medical support are currently eligible but not enrolled in Medicaid or Medicare. Similar programs already exist in multiple large city or safety net hospitals with results showing a more effective use of financial and clinical resources.
  • Scalability: We expect that our program can be easily scaled up to not only provide treatment for higher quantity of patients, but also customized to different types of patient needs (i.e. patients who require ongoing substance use/mental health support, transitioning from jail/prison system, street homelessness).
  • Feasibility: The flexible care model that we provide (see above) is more feasible than the traditional clinic model for most patients dealing with housing, substance, mental and medical issues. Through a rotation schedule, our team or providers are able to provide care on a daily basis without overstretching our allowed FTE.
  • Evidence Based support: Multiple studies revolving around a similar intensive primary care programs have shown cost saving or no increase in annual cost with increased service access, appropriate care utilization, an improvement in quality of care, and disease metrics.
  • Relevance to Medicaid: Most of the patients are expected to be on Medicaid or pending enrollment of Medicaid.
  • Speed to Market: The Bellevue Safety Net program is expected to initiate in 8/1/2018.

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):

Our program is ready to officially start on 8/1/18. We estimate a patient size of ~100 for the initial year and more in the following year with more providers and supportive staff.

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