Social Determinants of Health

4 Takeaways from Our NYC Panel Discussion on Social Determinants of Health

As we continue our CareMessage community event series across the country to inspire dialogue and knowledge sharing among FQHC leaders, we hosted our third and largest event yet in New York City last week with a panel discussion on “Addressing Social Determinants of Health through Patient Engagement.” New York City represents an important community for CareMessage as the metro hub of New York state with its more than 70 FQHCs with nearly 800 sites. We co-hosted the event together with investment firm, KKR, given our collaboration as one of three companies selected into their Social Entrepreneurship program in partnership with Echoing Green

We brought together local professionals from FQHCs and safety net organizations for a thoughtful discussion exploring Social Determinants of Health (SDOH) and the evolution of understanding, tracking and addressing these within a community health center setting. Our speakers included:

  • Moderator: Sonia Panigrahy, Senior Director, Quality and Technology Initiatives at CHCANYS

  • Panelist: Thomas Marino, Chief Transformation Officer at Harlem United 

  • Panelist: Jasdeep Cheema, Population Health Informatics Database Manager at Ryan Health

  • Panelist: Adena Hernandez, Program Officer, Health at Robin Hood Foundation

Our diverse panel offered a breadth of viewpoints from the operational, funder and technical perspectives exploring both challenges and progress made. Here are our key takeaways followed by highlight video clips and our full video session:

1. It All Starts with Identifying SDOH for Your Patients

Our panelists and moderator all agreed - while the term Social Determinants of Health is a newly coined one, addressing these have long been at the core work of any safety net organization.

Providers and staff may learn about the realities of their patients’ lives, but are faced with the reality that their clinic and organization may have no resources to help the patient. This is all too true in New York City, where a variety of social needs are especially common for underserved patients, making it difficult to direct patients to resources. Patients experiencing homelessness may find that shelters are at capacity or those seeking food find that pantries are closed.‍

“At the end of the day, everything that we do socially and everything that impacts our environment is going to have an outcome on our health care and we [healthcare providers] have to address these things."


- Thomas Marino, CTO, Harlem United

When asking patients about safety at home, Harlem United’s CTO Tom Marino described that they learned that they needed to open a women’s shelter as they learned that they had a patient population who were victims of female genital mutilation (FGM). Though they expected that safety at home might be a concern, they had the realization that there were forms of violence they otherwise had not realized members of their community had faced.

2. Technology Can Make SDOH Identification Easier But Requires Testing

Ryan Health’s Jasdeep Cheema discussed the use of iPads in the patient waiting room, as well as in patient visit rooms as a way to determine if patients’ total time in the clinic could be optimized. This was a shift for Ryan Health, as it had previously been having staff conducting the PRAPARE survey with patients and through motivational interviewing.

Cheema also described how Ryan Health has considered the use of notes in the patient chart in the EMR as a way to track ongoing patient needs. Providers and staff could log if they had referred a patient to services and resources -- like a transportation service, a shelter or food bank -- and also potentially view patients with ongoing needs that the health center hadn’t been able to refer services for. Cheema acknowledged that while this might be helpful, it did not solve for the fact that oftentimes providers and staff have no way to know if a patient actually received services.

3. Take Steps to Make SDOH Data Actionable

Our panel spoke openly about how addressing SDOH takes incremental steps and developments. And while collecting data may take time, when certain needs arise, FQHCs need to find ways to take action, but don’t have to go it alone.

We heard from Robin Hood’s Adena Hernandez that when data is available and smaller scale models have been proven out, take those findings to foundations who can potentially help fund initiatives.

Harlem United’s Tom Marino described the free jitney service offered to those in the communities they serve and when certain needs can only be addressed by partner organizations, seek out ones in your community.

4. Tracking Impact Will Take Time and Continued Innovation

Innovations and pilots like ones run at Ryan Health put data at the forefront of being able to understand where FQHCs can have the most impact. Collecting data, running pilots, training staff and providers take time to ensure that the right investments are made over time and also to the patients who are in greatest need. As described by an attendee to the group, collaboration and sharing can help improve how FQHCs address their patients’ needs ultimately resulting in improved operations and outcomes for all.

There’s no single solution or silver bullet to helping an organization address all the social needs of their patient populations and figuring this out will take time, especially as FQHCs and the healthcare industry as a whole determine how providing social services might impact a health center’s bottom line.

Panel Highlights Video:

Full Panel Video:


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