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

Ariel Olswanger

Administrator, Essen Health Care

1436 Williamsbridge Rd





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

Essen Health Care´s mission is to provide the highest quality care to our patients by combining the latest advances in medicine, patient–centered compassionate care, and leading–edge information technology.

Our vision is to create an integrated healthcare delivery platform for high quality, accessible and cost effective care.

Our values come from almost 20 years of service to medically underserved communities and from the passion to innovate towards a better healthcare delivery system.

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).

Essen Health Care offers an integrated medical platform, providing needed services to some of the most underserved communities in New York state. Our clinical divisions include20 doctor´s offices, 15urgent care centers, 42 nursing homes, a house calls program with 7,000+ enrolled patients, and a chronic care management program with 3,500+ Medicare recipients. By developing a vibrant Health Homes Care Management Agency and leveraging our delivery system, we are able to comprehensively address the unique needs of our patients. The team of care managers works closely with Essen´s 250+ providers to improve health outcomes of its 1,500 active members.

One of the services offered by care managers and nutritionists is Diabetes and Hypertension Club, which meets monthly to provide health education in a social learning environment. The care management team also offers art therapy, Medicaid enrollment and re–certification on–site, as well as connection to over 30 community–based partners who provide services including affordable housing, job development, educational courses, and food access. Through this program, all five major social determinants of health are addressed, reflecting each member´s unique needs.

In an effort to leverage Essen´s current model and existing knowledge base, we are building a resource portal called Essen Cares that can serve as a community resource, irrespective of an individual´s Health Home eligibility status. The Essen Cares portal is intended to improve the health of the communities we serve by addressing social determinants of health from the doctor´s office. All patients will have the ability to use the portal to efficiently access quality resources in the Bronx, based on a patient´s eligibility and need. Each resource in the portal will have contact information and a process for streamlined referrals.

Q5 Was your innovation implemented? If so, please explain when, the number of people impacted, and the results.


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