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

Bridgette Wiefling

Senior Vice President Primary Care & Ambulatory Specialty Institute

100 Kings Highway S





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

Rochester Regional Health (RRH) is an integrated network of high quality, community–focused healthcare services offered across the continuum of care at over 150 locations, including five hospitals (with a total of 1,723 beds), and more than 100 primary and specialty practices, rehabilitation services, innovative senior services, home health programs, outpatient laboratories, surgical centers, and imaging centers. Serving individuals throughout western New York and the Finger Lakes region, the mission of RRH and its affiliates is "to enhance lives and preserve health by enabling access to a comprehensive, fully integrated network of the highest quality and most affordable care, delivered with kindness, integrity, and respect." With over 17,000 employees we are the second largest employer in our region and account for approximately two million patient encounters annually.

We are a safety net provider for the greater Rochester region. Many of the individuals served by RRH experience significant barriers to care, such as diverse cultural backgrounds and exceptionally high rates of extreme poverty, and as a result, our care continues to evolve as we identify ways to address these barriers to care, and to engage patients in their healthcare. We share the social determinants of health intent in creating social and physical environments that promote good health for all. As such, we welcome the opportunity to share with the New York State Department of Health the importance of the Transitional Housing project.

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).

Homelessness is one of the leading factors that contribute to hospital utilization and the security and stability of housing is a major influence in the social determinants of health. "Prior research has found that people who are homeless are hospitalized more frequently and may have longer lengths of stay and higher hospital costs" (Doran et al., 2015). The stress of housing and affordable housing leaves our patients and community with a strain on access to healthy foods, healthcare services and overall poor health. The ability to provide homeless patients with a supportive place to transition back into the community after hospital discharge is an important factor that can improve the health and recovery of our patients. Adequate housing coupled with Mental Health Services and Chemical Dependency Services results in an increase in compliance with medication, doctor visits, and support service visits which leads to long periods of sobriety and mental and physical wellness.

Throughout the Rochester Regional Health network, multiple challenges are faced when discharging patients from the hospital that are homeless. Patients typically are admitted longer, and due to a lack of supportive and stable housing once discharged, they frequently end up back in the hospital. The lack of stable environment also influences the completion of follow up appointments with medical, behavioral health, and substance abuse providers.

Over 400 patients admitted were identified homeless or at risk in 2017 at RGH, Unity & St Mary’s. Thankfully, 49 of these patients were able to get a transitional bed; 92% of these patients had some form of active Medicaid. The transitional supportive housing program aims to assist homeless or unstably housed patients in a collaborative care model to work on getting them into permanent housing. The hospital partners with a Community Based Organization to work with the patient at the transitional site rather than the hospital to reduce unnecessary hospital use and provide a safe environment for the patient to recover and work on long term plans.

Patients that are homeless or at risk of homelessness are identified in the hospital, and based on screening and availability, then discharged to a transitional bed. At the community transitional site, patients receive support by staff to medically recover, maintain medical & behavioral health appointments and focus on attaining permanent housing. At the home, patients are provided with three meals a day, a place for homecare to see them, medication reminders, support in arranging transportation for medical and behavioral health follow up appointments and permanent housing assistance from a Housing Specialist & Health Home Care Manager.

The programs objectives are to decrease Medicaid costs and reduce unnecessary hospital use by decreasing ED visits, admissions, readmissions and hospital length of stay by providing a supportive environment with the goal of getting patients into permanent housing.

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):

Since the program inception at the end of 2015, our over 130 patients have gone into a transitional bed, with 80% of them being placed in permanent housing on an average of 45 days after hospital discharge. For all transitional housing patients’ Inpatient admissions 12 months prior to program enrollment versus 12 months after decreased by 24% and their length of stay has decreased 37% from with the number of admitted hospital days decreasing from 1,961 prior to 501 post enrollment*. We believe this data truly highlights the importance of housing while combined with support & resources on hospital utilization and the overall well–being of the people in our community.

Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)

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