Friday, October 4, 2024
10/4/2024
Since 1990, Housing Works (HW) has worked tirelessly to provide services and increase healthcare access to historically underserved and marginalized populations in New York City (NYC). As a federally qualified health center (FQHC) with a Health Care for the Homeless Program, HW provides primary, behavioral health, and social care services to people with co-occurring chronic conditions such as HIV/AIDS, behavioral health conditions, substance use disorders, homelessness, and other social service needs. As Medicaid reform advanced in New York State, HW and other community-based providers came together to establish the EngageWell Independent Practice Association (EW IPA). Today, EW is a well-established network of 20 non-profit organizations, many of whom were members of the advocacy groups, that pilots and evaluates innovative health equity interventions that hope to break the links between poverty, structural racism, and poor health, and negotiates Managed Care contracts that enhance or expand Medicaid services. In July 2022, EW launched an ambitious, pilot initiative, dubbed “Care Your Way,” (CYW) integrating medical care, behavioral health, and social determinant of health (SDOH) services through a targeted, population-health approach using smartphone-based SDOH services and on-demand virtual medical care to its highest-need clients. The overarching and unifying aim of EW is to improve health disparities based on race and socioeconomic status. EW’s CYW model directly addresses health disparities experienced by Black and Latinx New Yorkers. HW, with the EW IPA as the lead project administrator, seeks to support the continuation and specialization of CYW, with a focus on addressing two Leading Health Indicators (LHIs)—high-blood pressure and food insecurity. In the broader public health context, the CYW project integrates SDOH into outpatient primary care. This is particularly significant for underserved and minority populations who have been systemically and historically denied access to preventive healthcare and resources that promote health. The LHIs are impacted by Health Care Access and Quality (SDOH 1) and Economic Stability (SDOH 2). Poverty and socioeconomic stressors, like food and financial insecurity, are common barriers to initiation and sustained engagement in medical care and behavioral health treatment. The overarching goal of the proposed program is to demonstrate that the three (3) community level and digital health innovations that make up CYW—food security, medication adherence, and virtual medical screening and referral—which are augmented by digital health technology and wraparound Community Health Worker support, increase the use of preventive health services, make progress toward the selected LHI targets for racial and ethnic minorities, and improve the selected SDOHs. EW IPA will also implement a comprehensive evaluation that demonstrates a proof of concept and return on investment to support sustainability and scalability through managed care contracting. Over the 4-year project, 1,200 unique clients will participate in Wellth (medication adherence intervention) and/or Tangelo (food security intervention), and EW IPA will complete 1,200 virtual health screenings in non-clinical settings via Rocket Doctor (virtual medical screening and referral intervention).
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).
