A program of NYC Health + Hospitals, the largest public health care system in the nation, is launching two programs to address food and housing insecurities.
OneCity Health, the NYC Health + Hospitals Performing Provider System under New York State’s Delivery System Reform Incentive Payment (DSRIP) program, announced the Food and Nutrition Service Network and Housing Navigation Network will connect patients to available services that are traditionally fragmented and difficult to navigate.
Three lead community-based organizations (CBOs), BronxWorks, Public Health Solutions (PHS) and RiseBoro, will be awarded a total of $4.3 million to 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. The contracts will run through December 2020.
“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,” said Israel Rocha, CEO of OneCity Health and vice president of NYC Health + Hospitals, in a statement. “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.”
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.
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 for housing instability, food insecurity, and other social service needs. Navigators will use a standard form to determine a patient’s need.
Using NowPow, 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.
The NowPow web-based social directory will help navigators search for services that meet the cultural and linguistic needs of patients referred for housing and/or nutrition support services. Through NowPow’s tracking and evaluation functions, navigators will know if their client received the service and follow up appropriately depending on the circumstance.
Last year, Healthcare Innovation wrote about how the Trenton Health Team, a community health improvement collaborative serving Trenton, N.J., had begun working with Chicago-based NowPow to better connect Trenton residents to clinical and social services to improve their health and well-being. Providers at social service and healthcare organizations in Trenton can conduct screenings to generate a customized list of social services tailored to a patient’s specific needs and geography. More than 25 Trenton-based organizations have already signed up to use the NowPow platform.
Trenton Health Team’s implementation of the NowPow platform includes integration with its own HIE. The integration of these two technology platforms will, for the first time in Trenton, provide clinicians across the community with the ability to view a patient’s health and social conditions in a single location.
Here is more detail OneCity Health provided about the funding for the lead community-based organizations:
Lead Organization: BronxWorks
Focus: Housing
Budget: $247,500
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)
Focus: Food
Budget: $2,652,841
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. PHS will organize a network of 12 CBOs to conduct outreach and handle referrals.
Lead Organization: RiseBoro
Focus: Food and housing
Budget: $1,431,483
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. It will organize a network of 13 CBOs to conduct outreach and handle referrals.
