NYC Partnership Targets Medicaid Population for HRSN Screenings

A multi-stakeholder partnership has set an ambitious goal of completing 40,000 health-related social needs screenings across their shared Federally Qualified Health Center (FQHC) network in New York City by June 30, 2026. 

Executives from Yuvo Health, a value-based care enablement partner to community health centers; Public Health Solutions (PHS), one of the city’s largest public health nonprofits; and Hyphen, a data integration company, recently spoke with Healthcare Innovation about their partnership, which will assess patients for unmet needs such as food insecurity, housing instability, and transportation barriers, and connect them directly to community-based support services.

Zachariah Hennessy, chief strategy officer for Public Health Solutions and executive vice president of its WholeYouNYC network, said the partnership is operating under New York State's 1115 Health Equity Reform program, which runs through March 2027. His organization will facilitate referral pathways and service coordination to ensure patients receive timely assistance. PHS has assembled 200 community partners at WholeYouNYC, supporting the 2.3 million Medicaid members in Queens, Brooklyn and Manhattan. “But the infrastructure that we are building and the way that the state has designed it is clearly focused on creating this as a permanent part of Medicaid through the way the way rates are adjusted for people with clinical conditions.”

Through its independent practice association (IPA) network, Yuvo Health is supporting an initial cohort of New York City FQHCs, including Joseph P. Addabbo, Housing Works, and Boriken Neighborhood Health Center, in implementing screenings. Janel Sia, chief strategy officer and co-founder, of Yuvo, said implementing this program is tricky because the resources of this social care network are for Medicaid members only. 

“We all know that healthcare providers don't just serve people on Medicaid, so they're in a real tough spot. If they do universal screening, they have to have a solution for people who are not on Medicaid, and there are no resources through this healthcare reform for those patients,” Sia explained. “So instead of making them screen everyone and then only support some, which is not really an equitable approach or efficient, we’re able to highlight for providers the members who are eligible for screening at the point of care, so that they know that the person sitting in front of them is eligible for screening and may be eligible for these services as well.”

Yuvo has a network of 13 FQHC partners in New York. Sia explained that Yuvo is embedded into their clinical workflows, because it supports them as an IPA. “We contract on their behalf for different risk arrangements with managed care organizations,” she said. “As a part of that, we have tech-enabled population health and performance management teams that are at the health center sites, working with them on their workflows to improve any quality care gaps, as well as to make sure that we're performing within our contracts. We wanted to find a creative solution to make sure that they're getting their patients screened without overburdening them with more work to do.”

Healthcare Innovation wrote about health technology company Hyphen in 2022. The company is owned by the same parent company as New York-based insurer Healthfirst, but Hyphen is a payer-agnostic platform. Its platform is using FHIR to facilitate secure data sharing and integration between Yuvo Health, PHS systems, and Healthix, a Qualified Entity (QE) health information exchange operating under New York 1115 Medicaid waiver. Suzanne Wogelius, the company’s vice president of product management, noted that PHS has 2 million Medicaid members and Yuvo has providers and care managers working in FQHCs who don't want to leave their workflow. “We sit in the middle,” she said. “We enable these two partners to collaborate and to allow Janel’s team to have real-time access to data that we have on behalf of Public Health Solutions. One of the FQHC care managers can be working in their clinical workflow; when the patient is pulled up in that context, it pings Hyphen, which responds by signaling that yes, this is a PHS member, and they need to be screened. We’re enabling that screening to happen in multiple languages. The way that New York has defined the routing of information is that when a screening gets conducted, it goes through one of the many Qualified Entities or HIEs, and then it's routed to the state.”

Wogelius explained that Yuvo’s platform is integrated into the EHRs of the FQHC partners, so Hyphen is able to do this work by integrating with Yuvo rather than the EHRs themselves. “We talk about meeting providers where they are. We want to be flexible and very much want to integrate with infrastructure that has already been invested in,” she added. “We love working with Janel and her team, because they've already done that work with the FQHCs, and we can integrate into her solution.”

Although this screening project is just getting started, Hennessy said PHS did a similar custom interoperability with another partner that showed very positive preliminary results, which helped them determine that the goals they were establishing around screening were realistic and achievable.

This information about screening and services provided gets put into the Medicaid database through coded billable activity, which includes the screening and navigation and all the new services. 

“That's why we really believe that social care is here to stay in New York because of the permanent way that they have built it in,” Hennessy said, “Everything is being coded according to Gravity Project standards and billing and coding standards that are used for all of healthcare service delivery in New York. We're really excited that all that data is going to be together in the system, so you can really see the impact that the services that our community-based organization are having — mold and pest remediation in homes where someone has asthma or accessibility modifications for seniors who are transitioning out of the hospital, medically tailored meals for people with diabetes and hypertension, rental assistance for pregnant and postpartum folks. These are really critical moments in time for people, where social intervention can be incredibly impactful, and because it is all coded in the language of healthcare and using the same interoperability standards, it's going to live alongside and together, with all of the state's Medicaid data.”