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

Dr. Susmita Pati

Medical Director, Keeping Families Healthy

Stony Brook Children´s

Health Science Center, T–11, 020

Stony Brook




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

The overarching goal of Stony Brook Medicine´s Keeping Families Healthy (KFH) programis to help "at risk" families achieve self–sufficiency in navigating the health care system and adhering to recommended clinical care. The program is fully aligned with Stony Brook Medicine´s mission to "deliver world–class, compassionate care to our patients, advance our understanding of the origins of human health and disease, and educate the healthcare professionals and biomedical investigators of the future, so they can bring the fruits of scientific discovery toour patients." In particular, the KFH program serves patients (<18 yrs) deemed by referring clinicians to be "at–risk" for poor health outcomes, such as first–born infants, children with chronic conditions (e.g., asthma, obesity), psychosocial risk factors (e.g., limited English proficiency, insurance problems, limited transportation) receive Community Health Worker home visits (average 4–5 visits over 4 months) with additional phone/text message support as needed.

Q3 Please indicate which category your organization falls under.

Health Care Provider,

Community–Based Organization

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).

Keeping Families Healthy (KFH) was established in July 2011 and has been in continuous operation for almost 7 years. To date, CHWs have completed more than 4700 home visits for more than 1200 children. KFH demonstrates positive impact on health outcomes and family and provider satisfaction that translate into cost savings at the population level. We published our findings that program participation increases the absolute likelihood of up–to–date immunization status by 16.8% among infants/toddlers and 20.8% among newborns in Vaccine.1 Our results showing a 50% decline in ´preventable´ emergency room department visitsamongparticipants has been published in Pediatrics.2 We qualitatively evaluated the CHW tasks comprising successful program completion to facilitate replication was published in the Journal of Community Health.5 Trainees and program staffhave further presented the program´s functioning andimpact at national meetings for hospital leaders, community health workers, asthma educators, practitioners, and researchers. Family surveys completed anonymously show that 98.9% strongly agree/agree that ´The [KFH CHW]tookmy family´spreferencesinto account when addressingmychild´s health care needs while they were in my home´ and99.3%strongly agree/agree with ´When the [KFH CHW] left my home, I had a good understanding of the things I was responsible for in managing my child´shealthsuch asmaking appointments or following up on things discussed during the home visit.´ Anecdotally, clinicians report positivehealth impacts and family satisfaction; "saw patient today, and mother, in spite of language barrier, has significantly improved in terms of her understanding of asthma disease andmanagement"; "KFH hasbeen to the house. [Thepatient] and his mom came in with an asthma tool kit, all of hismeds, hisspacer, and thebinder...hehadno activitylimitations due to asthma...[He] and his mom spoke highly of KFH." As previously noted, our innovative programhas wonnational recognition and remains an industry leader in health care service delivery innovations. 1. Pati S, Ladowski KL, Wong AT, Huang J, Yang J. An enriched medical home intervention using community health workers improves adherence to immunization schedules. Vaccine. 2015;33(46):6257–6263. 2. Anugu M, Braksmajer A, Huang J, Yang J, Ladowski KL, Pati S. Enriched Medical Home Intervention Using Community Health Worker Home Visitation and ED Use. Pediatrics. 2017;139(5). 3. American Academy of Pediatrics. Promising Practices. 2017;–Practices–Archives.aspx. Accessed 5/31/18, 2018. 4. American Academy of Pediatrics. Examples of Care

Coordination in the Community. 2017;–resources/Pages/Care–Coordination.aspx. Accessed 5/31/18, 2018. 5. Justvig SP, Li J, Caravella G, et al. Improving Adherence to Care Recommendations Using a Community Health Worker (CHW) Intervention with the Pediatric Medical Home. J Community Health. 2017;42(3):444–452.

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