Social Determinants of Health Intervention Framework

This document is a case study detailing the implementation of social determinants of health (SDOH) interventions by an Independent Practice Association (IPA), Managed Services Organization (MSO), and Accountable Care Organization (ACO) in New York City. The customer, serving over 1 million patients, partnered with Regional Aid for Interim Needs, Inc. (R.A.I.N) to address food insecurity and housing instability among its members. The New York State Department of Health's Innovator Program supports provider organizations in achieving value-based payments for the Medicaid population. The case study outlines the challenges faced in tracking referrals and outcomes due to the lack of a centralized data tool. To address these issues, a custom referral intake tool was developed, enabling R.A.I.N staff to monitor outreach attempts and application statuses. The document presents the outcomes of this initiative, highlighting the number of referrals and cases closed, demonstrating the effectiveness of the collaborative approach in managing SDOH interventions.