Crafting an Effective SDOH Strategy Through a Social Care Network

By Eric Wicklund

Healthcare CIOs working on a strategy to improve health outcomes in underserved populations would do well to check out New York, which is investing $500 million in a new program addressing social determinants of health (SDOH).

The Social Care Network (SCN) program, unveiled this week by Governor Kathy Hochul, leverages state and federal funding to help Medicaid members access transportation, housing, nutritious meals and other social services. By addressing SDOH barriers, the state aims to reduce healthcare costs and improve outcomes.

“We traditionally invest healthcare dollars in direct patient care, yet it is often the factors ‘outside the exam room’ that most need to be addressed,” New York State Health Commissioner James McDonald, MD, said in a press release. “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.”

Addressing SDOH and health inequity is a key concern for healthcare leaders, and innovative partnerships like the SCN show potential in pushing the right resources to the right populations. A good proportion of halthcare waste is directly tied to barriers to care, which keep patients from accessing the services they need until their health declines. This leads to expensive health interventions, including ED visits and hospitalizations, and continuing care for medical issues that could have been managed or even prevented.

The $500 million will be disbursed in awards to nine social care organizations across the state. The program, administered through a Medicaid Section 1115 Demonstration Waiver, is part of a three-year, $7.5 million effort, which includes almost $6 billion in federal waiver funding.

As proof of the program’s potential clinical benefits, officials pointed to New York’s Medicaid Redesign Team Supportive Housing Initiative, which provides permanent housing and support services for homeless residents with medical conditions. That program, officials said, led to:

  • A 40% reduction in hospital inpatient stays
  • A 26% reduction in ED visits
  • A 15% reduction in overall Medicaid health expenditures
  • A 44% reduction in admissions for substance abuse rehabilitation
  • And a 27% reduction in inpatient psychiatric admissions.

In addition, officials said, the program helped the Medicaid program save $46,500 per person per year by prioritizing treatment for patients with some of the most complex care needs.

“Every year, hundreds of thousands of New Yorkers avoid healthcare due to concerns about money, housing, food, transportation, and other unmet needs,” Zachariah Hennessey, executive vice president and chief strategy officer of Public Health Solutions, one of the nine organizations receiving a grant, said in the press release. “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.”