– OneCity Health is the NYC Health + Hospitals-sponsored Performing Provider System (PPS) launches two new programs worth $4.3M in total to address food and housing insecurities among patients of the City’s public health system.
– As part of the initiative, OneCity Health will partner with NowPow to utilize their personalized community referral platform to enable community-based organizations to connect patients to available services that are traditionally fragmented and difficult to navigate.
– Approximately 5,500 New Yorkers will be connected to food and nutrition services, while an additional 420 will receive assistance accessing housing services through these partnerships.
OneCity Health, the NYC Health + Hospitals Performing Provider System under New York State’s Delivery System Reform Incentive Payment (DSRIP) program has announced the launch of two new social determinants of health (SDoH) programs to address food and housing insecurities among patients of the City’s public health system.
$4.3 Awarded to 3 Lead Community-Based Programs (CBOs) to Organize Network of 26 CBOs
The Food and Nutrition Service Networks and Housing Navigation Network will connect patients to available services that are traditionally fragmented and difficult to navigate. OneCity Health awarded a total of $4.3M to three lead community-based organizations (CBOs):
Lead Organization: BronxWorks
BronxWorks will lead the Bronx housing navigation services, which will include helping housing insecure individuals access mobile vans that will take them to Safe Haven beds. BronxWorks will ensure that the individuals remain connected to their shelter designation.
Lead Organization: Public Health Solutions (PHS)
PHS will deploy its Food and Nutrition Service Bundle (FNS Bundle) model and will offer Stanford Diabetes Self-Management classes in NYC Health + Hospitals facilities in the Bronx, Manhattan, and Queens. The FNS Bundle program offers screening and navigation to community food and nutrition resources for food insecure patients and connects them with more than one resource, including SNAP, WIC, medically tailored home-delivered meals, food pantries, congregate meals, individual and group nutrition counseling, and sources of fresh produce. The Stanford Diabetes Self-Management program (DSMP) is an evidence-based six-week group program for people with type-2 diabetes. It provides information and skills to individuals so that they can manage their diabetes symptoms. PHS will organize a network of 12 CBOs to conduct outreach and handle referrals.
Lead Organization: RiseBoro
Focus: Food and housing
RiseBoro will lead efforts in both food and nutrition, as well as lead the Brooklyn housing navigation. Clients will have access to cooking classes, farm shares and the diabetes self-management classes to help address challenges with food and nutrition access. RiseBoro housing navigators will focus on individuals who are housing insecure or who may have fallen behind in their rent payments. RiseBoro will also connect individuals to providers who can help them complete applications for permanent affordable housing placements. RiseBoro will organize a network of 13 CBOs to conduct outreach and handle referrals.
Together, the three CBOs will organize a network of 26 smaller CBOs to assist with outreach and referrals to available services, such as Safe Haven beds and eviction prevention services for those facing housing insecurities, and food pantries and SNAP enrollment for those facing nutrition challenges.
Approximately 5,500 New Yorkers will be connected to food and nutrition services, while an additional 420 will receive assistance accessing housing services through these partnerships. The contracts will run through December 2020.
CBO Programs Approach
A housing and/or food navigator from one of the 26 CBOs will be stationed in all 11 NYC Health + Hospitals acute-care facilities and NYC Health + Hospitals/Gotham Health, Belvis and Morissiana, where they will receive patient referrals from on-site social workers and clinical teams. The patients will be screened to assess housing instability, food insecurity, and other social service needs. Navigators will use a standard form to determine a patient’s need.
Partnership with NowPow
As part of the programs, OneCity Health and NYC Health + Hospitals is partnering with NowPow, a personalized social service directory and referral platform that makes it easy to connect people to just the right community resources. Utilizing NowPow’s platform, navigators will check for eligibility and then match and connect patients with the community resources that can best meet their identified needs. NowPow allows the navigator to identify these community resources. The housing and food navigators will also have information tables set up at the facilities where patients can self-refer.
Through NowPow’s tracking and evaluation functions, navigators will know if their client received the service and follow up appropriately depending on the circumstance.
How SDoH Impact Health Outcomes
According to the New York City Neighborhood Atlas, approximately 5.3 million New York City residents are housing insecure. Food Bank NYC estimates that more than 1.2 million New York City residents are food insecure.
The CDC defines “social determinants of health” as the circumstances in which people are born, grow up, live, work, and age. This also includes the systems in place to offer healthcare and services to a community. Recognizing that a lack of access to healthy, affordable food and stable housing is a key driver of poor health outcomes, OneCity Health has focused on connecting NYC Health + Hospitals patients to social services that address these needs.
Disruptions in food availability are associated with poor health outcomes and increased health care utilization. Housing homeless people has consistently been shown to improve health outcomes, including reducing psychological distress, substance use complications, and intimate partner violence.
Improving The Patient Experience by Addressing SDoH
“OneCity Health is bringing health centers and community partners together to provide services that can address whole-person care as part of our ongoing effort to transform the health care delivery system under DSRIP,” said CEO of OneCity Health and Vice President of NYC Health + Hospitals Israel Rocha. “By helping patients access and more easily navigate resources like affordable foods or housing, we can create a seamless experience for patients to address both their clinical and social needs. A critical part of the DSRIP program has been building the underlying infrastructure that can facilitate these connections and get patients to the right resources. We are excited to partner with NowPow who will provide the referral platform for these programs.”
The recent implementation of PHS’ FNS Bundle model through OneCity Health’s Innovation Fund in the Bronx resulted in 871 families being registered for food and nutrition programs, with nearly 60 percent of participants screened being enrolled in one or more food and nutrition services. The proportion of families in need of emergency food resources who were able to access such resources rose from six percent to 56 percent.