Social Care Networks Will Help Address Health Disparities by Connecting Medicaid Members With Subsidized Nutritional Meals, Housing Supports, Transportation and Other Critical Services

Program is Part of 1115 New York Health Equity Reform Waiver Approved in January

Governor Kathy Hochul on Aug 7th, announced that nine organizations statewide will receive a total of $500 million in awards over the next three years to create a new Social Care Network (SCN) program in New York State. The program will address health disparities in low-income communities by leveraging federal funding to facilitate Medicaid members access to nutritional meals, housing supports, transportation and other social services that can have a significant impact on an individual’s health. By integrating social care and health care, this program advances a key initiative under the New York Health Equity Reform (NYHER) waiver amendment.

“The Social Care Networks will help us transform how we support communities with the greatest unmet needs,” Governor Hochul said. “Through the SCN program, we are making a direct investment in the health and wellbeing of our local communities - and New Yorkers will be connected to a more equitable and integrated social and health care system.”

New York State, as part of its Medicaid Section 1115 Demonstration Waiver, is making an historic step forward to create a new model of care that will integrate health care and social care via networks with associated funding. The $500 million program is one component of a $7.5 billion three-year waiver with nearly $6 billion of federal funding. The SCNs will be core to facilitating the delivery of health-related social needs, including nutrition, housing supports, transportation, and case management for eligible Medicaid members, which are essential to addressing health disparities and improving population health.

Data shows that subsidizing health-related social needs can have significantly positive impacts on health outcomes for low-income New Yorkers.

For example, a program known as the Medicaid Redesign Team Supportive Housing Initiative is focused on providing permanent housing and tenancy support services to homeless New Yorkers with medical conditions. An analysis of the program showed that investing in housing supports led to better health outcomes such as:

• 40 percent reduction in inpatient days
• 26 percent reduction in emergency department visits
• 44 percent reduction in patients with inpatient substance use rehab admissions
• 27 percent reduction in patients with inpatient psychiatric admissions
• 15 percent reduction in overall Medicaid health expenditures
• Through strategic prioritization, the top decile of enrollees had average Medicaid savings of $45,600 per person per year

The following organizations were selected and will be covering nine regions throughout the State:

Organization	Region
Care Compass Collaborative	Southern Tier
Finger Lakes IPA Inc.	Finger Lakes
Health and Welfare Council of Long Island	Long Island
Healthy Alliance Foundation Inc.	Capital Region, Central NY, North Country
Hudson Valley Care Coalition, Inc.	Hudson Valley
Public Health Solutions	Manhattan, Queens, Brooklyn
Staten Island Performing Provider System	Staten Island
Somos Healthcare Providers, Inc.	Bronx
Western New York Integrated Care Collaborative Inc.	Western NY

New York State Health Commissioner Dr. James McDonald said, “Awarding the Social Care Network Lead Entity contracts represents a critical milestone toward advancing health equity, eliminating health disparities, and addressing health-related social needs. We traditionally invest health care dollars in direct patient care, yet, it is often the factors ‘outside the exam room’ that most need to be addressed. This historic investment allows these partners to connect patients to factors that often most influence our health, such as finding stable housing, reliable transportation, health insurance and other factors that improve people’s personal health.”

State Medicaid Director Amir Bassiri said, “These Social Care Network awards will transform how health care and social care are delivered. These networks are central to achieving the health equity goals of the NYHER waiver, and will complement our long term strategy to incorporate social care benefits into the Medicaid Managed Care program.”

Senate Majority Leader Charles Schumer said, “I am proud to help deliver this $500 million investment – part of a whopping $6 billion in federal waiver aid – so New York state can create this exciting and innovative Social Care Network to better integrate social care and health care to improve health outcomes for those in our most disadvantaged communities. It is a creative approach to health care that can save lives and, over time, save money by dealing with health care problems in needy communities more proactively and more holistically. From the Bronx to Watertown to Buffalo, local non-profit organizations in the Social Care Network will address housing, food, transportation needs, as well as health care so that fellow New Yorkers in need receive the support they need to be healthy and thrive. I am grateful for Governor Hochul’s work ensuring that these federal resources are being invested well to help people across New York access critical social services.”

Senator Kirsten Gillibrand said, “Today, New York is committing hundreds of millions of dollars to addressing health disparities in low-income communities and improving health outcomes for countless New Yorkers. The SCN program will be a lifeline for many and expand access to nutritional meals, housing support, transportation, and other social services. I am proud to support Governor Hochul’s commitment to advancing health equity and will continue to fight at the federal level to address health disparities in New York and nationwide.”

Representative Jerry Nadler said, “I applaud on Aug 7th’s announcement of $500 million to help improve the health of millions of New Yorkers. The nine organizations named today will serve as lead entities for New York’s groundbreaking Social Care Network (SCN) program. The new SCN program will connect the most underserved New Yorkers to critical social services, including housing, nutritional programs, and more.”

Representative Paul Tonko said, “I am thrilled to celebrate this significant investment that underscores our commitment to addressing the root causes of the health disparities that impact our communities every day. By integrating our health care system with essential social services, this investment advances a focused, comprehensive approach to fostering healthier, more equitable communities and improving the well-being of low-income New Yorkers here in our Capital Region and across the state.”

Representative Adriano Espaillat said, “Thank you Governor Hochul on this latest effort to expand funding for services to further advance the health and well-being for low-income New Yorkers. This funding helps propel the engagement of nine organizations across our state to further their support of families in need by facilitating Medicaid member access to meals, housing support, transportation, and other social services. On Aug 7th’s announcement reaffirms our work to address health disparities in our communities and builds on our collaborative efforts to support vulnerable families in our communities when they need our help the most.”

Representative Ritchie Torres said, “Social services and access to health care resources are crucial to the daily functioning of Bronxites. The significant investment from the 1115 waiver in Social Care Networks will help improve services and support systems for countless of low income residents throughout the Bronx. I especially want to extend my congratulations to Somos Healthcare Providers for being selected to receive an award which will go towards assisting Bronx residents in need. These SCN’s are essential to improving health equity for Medicaid Members and I look forward to working with the Governor to further expand and upgrade these programs and services.”

Representative Pat Ryan said, “Every Hudson Valley family deserves comprehensive healthcare and access to quality social services. I’m proud that these federal funds will remove barriers to care, helping the Hudson Valley Care Coalition deliver everything from housing to nutrition to transportation. Thank you to Governor Hochul for championing this key issue – I’ll keep fighting every day to lower costs and deliver relief for Hudson Valley families.”

Representative Dan Goldman said, “By integrating social services such as housing, nutrition, and transportation with health care, this historic investment will directly tackle inequality in our state and ensure that all New Yorkers can thrive, regardless of their income or background. I commend Governor Hochul for creatively utilizing federal aid and spearheading this new care model to more comprehensively support low-income communities suffering from decades of underinvestment. I am eager to continue working with federal, state, and local officials to ensure that these investments reach the people who need it most.”

Representative Tim Kennedy said, “This transformational funding will jumpstart New York’s Social Care Network, connecting eligible individuals with the healthcare and services they need to thrive. Healthcare is one component of overall health, which is why this initiative provides Medicaid recipients with more holistic support to secure nutritious meals, housing, and transportation. In my district, I look forward to the Western New York Integrated Care Collaboration Inc. delivering more equitable and impactful care to those who need it most.”

New York City Mayor Eric Adams said, “By establishing Social Care Networks that deliver on-the-ground services from trusted community partners, we are investing in the long-term health care of our communities. The health and well-being of New Yorkers is a priority for our administration, and that is why we launched 'HealthyNYC,' to expand the average life expectancy of all New Yorkers, and why we worked closely with our state partners to directly address the mental health harms caused by social media companies, particularly for our youth. We applaud Governor Hochul for her efforts here and look forward to working with the Social Care Networks in New York City.”

Albany Mayor Kathy Sheehan said, “I am grateful to Governor Hochul for investing $500 million to help break down barriers and ensure our most vulnerable neighbors are connected with both the social and health care services they need. The City of Albany – utilizing our opioid settlement funds – and Albany County recently partnered to create the Albany Navigates street treatment initiative to bring health and social resources directly to those in crisis, and this new Social Care Network is another way government is working to combat the health and social challenges we see across our city, region, and state. I look forward to working with New York State and our local partners to expand the reach of these much-needed programs.”

Rochester Mayor Malik D. Evans said, “Our most vulnerable residents are fighting every day to break free from a tangled and interlaced web of disparity that perpetuates the relationship between poverty and reduced health outcomes. I applaud the innovation and vision of Governor Hochul and the New York State Department of Health that led to the development of the Social Care Network Program. By confronting the complexities of health disparities with a comprehensive approach to social inequity, this program will advance our goals to create a safe, equitable and prosperous Rochester by inspiring hope and delivering opportunity for everyone.”

Utica Mayor Michael P. Galime said, “Connecting people who are in need of, or depend on, services essential to living a successful day to day life is a key aspect of what we hope to see this funding address in our community.”

Care Compass Executive Director Mark Ropiecki said, “Care Compass is deeply honored to serve as the Social Care Network (SCN) lead entity for the Southern Tier Region. As a former PPS during the DSRIP waiver serving the Southern Tier Region, Care Compass has a longstanding focus on enhancing access to care, improving quality, and reducing healthcare spend for Medicaid members in the community. Care Compass now looks forward to working with the State and other SCNs to advance health equity and reduce health disparities by connecting the community with these new services. The Southern Tier Region is a leader in healthcare innovation and delivery system transformation and is very well positioned to continue this important work in serving the Medicaid population.”

Forward Leading IPA, Inc. Executive Director Patty McMahon said, “FLIPA is honored to be able to elevate the essential role that community-based organizations play in healthy communities and to integrate their work within the existing primary care and behavioral health care system. It is well established that physical healthcare only accounts for about 20% of overall health and well-being. This is an opportunity to acknowledge that fact and change the lives of eligible Medicaid members by systematically addressing their health-related social care needs.”

Health and Welfare Council of Long Island of Long Island Executive Vice President Lori Andrade said, “HWCLI is honored to be selected as the lead entity for the Health Equity Alliance of Long Island (HEALI), the Social Care Network on Long Island. The HEALI network of community based organizations, health systems, Federally Qualified Health Centers and community partners has been collaborating since 2017 to integrate social care, healthcare and behavioral healthcare. We are committed to being trailblazers in this rare and unique opportunity to transform the way in which we think about health, well-being, and care. We thank Governor Hochul and Commissioner Bassiri for this once -in-a-lifetime opportunity to revolutionize the way we address the needs of individuals and families across the Island. With Medicaid clients at the center of this care model, more Long Islanders will have access to care, improved outcomes and greater well-being.”

Healthy Alliance Foundation, Inc. CEO Erica Coletti said, “Together with our partners, we’ve built a diverse and proactive network centered around the community member, having helped more than 275,000 to date. This state-wide commitment to redefine how care is delivered further validates the work we’ve been doing over the last decade, and we’re honored – and prepared – to be part of this monumental next step to ensure more New Yorkers have the same opportunity to be healthy.”

Hudson Valley Care Coalition CEO Amie Parikh said, “Hudson Valley Care Coalition is honored to have been selected as the Social Care Network for the Hudson Valley. Our network of over 150 organizations, including Community Based Organizations, hospitals, Federally Qualified Health Centers, county governments, and behavioral health agencies has a noble purpose of ‘Creating Communities of Health and Wellness for ALL.’ We stand ready to make the inaugural Hudson Valley Social Care Network a reality and a foundation of an ecosystem of healthcare that embraces a whole person approach. Our Network is committed to improving access, health equity and health outcomes that matter for the 720,000 Medicaid recipients in Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster and Westchester Counties.”

Public Health Solutions Executive VP & Chief Strategy Officer Zachariah Hennessey said, “Every year, hundreds of thousands of New Yorkers avoid healthcare due to concerns about money, housing, food, transportation, and other unmet needs. They turn to healthcare only when in crisis and their lives are cut short. Through New York State’s Health Equity Reform initiative, we have a once in a generation opportunity to change this trajectory and ensure Medicaid beneficiaries receive the resources they need on time to achieve optimal health for themselves and their families. This major investment will expand WholeYouNYC, our coordinated, technology-enabled network of community-based organizations that provides critical resources in Queens, Brooklyn, and Manhattan to ensure that New Yorkers have facilitated, easier access to the services they need.”

Staten Island Performing Provider System Executive Director Dr. Joseph Conte said, “The Staten Island PPS is honored to be recognized by Governor Hochul to serve the people of Staten Island as the lead entity for the Social Care Network. Confronting health inequity means addressing the fact that a person’s zip code is more predictive of their life expectancy than their medical conditions -- this requires a paradigm shift. That shift positions SCNs and Community Based Organizations in a unique model of care that leverages innovation and the collaborative efforts of health systems, FQHCs’, care givers, managed care and technology partners. SI PPS is committed to working with the DOH and the 8 other SCNs to improve health outcomes for all New Yorkers, especially those suffering from health disparities.”

SOMOS Healthcare Providers Chief Operating Officer Lidia Virgil said, “SOMOS has pioneered Social Care in underserved communities for many years now. As the largest minority led network of physicians in New York, we work at the intersection of health care and social care, that is who we are. SOMOS is proud to join with New York State to change the lives of our people in the Bronx. Every person who has food to eat, a way to get to their doctor, a place to live, finds respect and equity in our society. We are healthier when all of us have access to the basics of the American Dream. The SOMOS Social Care Network will be transformative and historic.”

Western New York Integrated Care Collaborative, Inc. Executive Director Nikki Kmicinski said, “We are honored and excited to have been selected as the SCN Leader for New York state’s Western Region. This is truly different. This isn’t business as usual. It’s a game-changer for our member organizations – which have grown by 65% in the last 18 months — allowing them to focus even more of their resources and efforts on the delivery of services throughout our community. It also validates the strong work we’ve done to date of improving member efficiency, eliminating costly redundancies, and producing data that shows we make a real, tangible difference in people’s lives. Our region is known for being good neighbors. We aim to embody this sentiment by being a fair, responsible and collaborative steward of these funds.”

SCN Lead Entities will connect Medicaid members to critical support by contracting with social service providers to help Members navigate and access services. Each SCN Lead Entity will be a designated Medicaid provider and coordinate the delivery of services, including housing, transportation, nutrition, and care management, in their region. Medicaid members who need assistance with their unmet health related social needs will be connected to existing resources, such as housing, nutrition, transportation, and care management.

SCNs will be an essential mechanism to improve health equity for Medicaid members and increase collaboration between social service providers and other partners in the health care system, track member needs, and ensure timely referral to critical services.

More information about the SCNs can be found here.

More information about the New York Health Equity Reform (NYHER) waiver amendment can be found under the MRT 1115 Waiver Amendments tab here.