MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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

BMS Family Health and Wellness Centers, founded in 1982 is a long standing federally qualified health center with the mission to provide and promote high quality medical and social services so that residents in the communities we serve can achieve lifelong total health and wellness. We are also one of the first freestanding health centers in Brooklyn accredited by the Joint Commission are a Patient Centered Medical Home LVL 3. BMS is multi–sited throughout East Brooklyn with four locations in Brownsville and four locations in East New York. Since its opening in 1982, BMS has served the equivalent of more than half the community´s residents – a testament to our mission. Today, BMS is a comprehensive health and wellness facility, serving 22,000 patients annually amounting to over 90,000 patient visits.

BMS´s geographic service area encompasses some of Brooklyn´s highest need areas including Howard HUB where according to NYCHA data, single parent households amount to 47% of the total and that increases to 55%, when single grandparents 'households are included. Among the widespread health conditions are: diabetes, obesity, mental illness, HIV/AIDS, substance abuse, poor oral health, prenatal care, low birth weight, teenage pregnancy, malnutrition, homelessness, and domestic and street violence. In 2017, BMS held weekly activations within the HUB playground that resulted in a visual art installation – Art in the Parks –that enhanced the "community feel" of the area. Further, after the project completion we continued with participatory planning sessions with stakeholders with the goal of building community engagement, ownership, and participation in the decision–making process toward creating a safe and healthy environment.

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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).

BMS@Howard HUB

The Need:

Brownsville, Brooklyn has been identified as the epicenter of a healthcare “hot spot,” one of three clusters of high poverty, densely populated census tracts in Brooklyn with poor distribution of primary care providers, An effective and lasting solution to this persistent problem requires paradigm shifts in the way health care is delivered and utilized. In addition to expanding and diversifying its own sites and services in response to patient demand and community need, BMS Family Health and Wellness Centers has achieved designation as a Level III Patient Centered Medical Home and has partnered with two other neighboring FQHCs to establish a patient-centered medical “neighborhood” to improve access to care and to ensure that patients and community residents are less vulnerable to gaps in services.

The Solution:

For several years BMS has engaged in neighborhood-level focused interventions that relate to food equity from our role as health providers’ facing high disparity in diet related illnesses within our community. This includes the Brownsville Food and Fitness Stakeholders, Farmacy (Food as Medicine), Youth Farms, Nutrition Education Summer Camps, WIC Programs and Diabetes Group Visits to most recently the development of the Healthy Village at Brownville a collaboration of an HMO, BMS, a Higher Ed Institution, Medgar Evers College and the Resident Association of Van Dyke Houses, a large public housing residence in the area. The goals of both programs are to improve the health outcomes of targeted New York City Housing Authority (NYCHA) and other area residents through collaborative interventions involving the HMO, a Clinical Partner and Community based organizations.

Specifically, in its current iteration BMS targets patients who are Health First clients and who reside in the area NYCHA residences for a Food and Fitness intervention located within the housing developments where participants reside. BMS and HF work collaboratively on the outreach to targeted participants and to engage them in twice weekly nutrition and exercise classes which culminate with a healthy meal including food demonstrations. During this latter part (post exercise) BMS staff engages participants around assistance for example with appointments e.g. for preventive quality measures such as Optometry Podiatry and Dental for Diabetic patients. During this meal period we also invite community partners e.g. a Job Training and Placement programs and Financial Advisors to present to clients.

However this was just a very modest component of what a larger plan to build cohesion and common planning for a neighborhood wide Food and Fitness revitalization plan with the goal of increasing access to healthy eating and active living options culminating in better health outcomes for area residents. This approach includes from the outset development of a sustainable model so when the funding goes away, the community has developed capacity to access resources for continued implementation.

The Results:

Healthy Village at Brownsville is now in its fourth year and has an annual attendance of over 100 participants and a core group of 30 women who work out twice weekly. Participants have individually improved their BMI measures and other health outcomes as measured by improvements in Quality Outcomes. As a community, core participants evolved into a leadership body e.g. attending CHCANYS Advocacy Day in Albany and most recently have begun work on Voter Education and Registration. Building on the successful design of the BMS@ Van Dyke -Healthy Village at Brownsville -BMS over the past year has moved into another housing development Howard Houses and to date have successfully fostered a stakeholder group focused on common planning for residents in Howard Houses. We have been successful in building this community cohesion through starting with an Art in the Park at Howard Summer program then successfully securing funding for a Hydroponic Farm in a Middle School in the HUB, A capacity building grant targeted at the playground that lies central to the school, library, Community center in the HUB and the Housing development itself. BMS@Howard HUB stakeholders are now as a group conducting common planning on a comprehensive design approach to health. As part of this we are in the process of creating a health checklist, by age groups, which will serve as the central lenses through which all partners across the HUB engage participants. For example, a standard health checklist tool that would be a part of applications for programs, afterschool, Camps and the basis for school wide screenings at the Elementary and Middle school in the Howard HUB.

Social Determinants of Health

This model cuts across several spheres in its design in that it allows for a planned approach to ensuring that the social determinants of health resources are in place across all populations. Moreover, that there is an integrated approach to the delivery of each. The Social Cohesion and Civic Participation is the foundation on which the design is built and this is with an eye toward a community centered approach to Access to Health care and Health Literacy ( e.g. the Howard HUB library allowing BMS to co-locate once per week providing navigation services) , Access to Healthy Foods ( the Hydroponic Farm and NYCHA Farm as well as the pantry at the Elementary School), Economic Empowerment (partnership with Workforce 1), Education through removing barriers that contribute to a high absentee rate among Brownville children, and fostering a Safe Neighborhood though space activation and community building.

The approach which is inherently a coordination of resources and partnerships that will translate into improved health outcomes has the potential for significant return on investment vis a vis a healthier population, it is scalable but requires and individualized approach respecting the unique nature of each community and there is a large body of evidence indicating that these approaches work. It is fact at the heart of the DSRIP model where prevention is key -and happens best through a community centered model. We find that much of the resources exit and it’s the application of time of a community coordinator and capacity builder that is central to the success.

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