Staten Island PPS is excited to announce the launch of their new Social Determinant of Heath app which surveys community members on their social needs and immediately connects them to resources.
A social determinant of health, or SDOH, is a factor that affects an individual’s health, but is often out of their control. These factors can be economic or social. They include education, housing, transportation, safety and access to food. A resounding 80.3% of Staten Islanders living with a chronic illness experience a Social Determinant of Health. According to The Robert Wood Johnson Foundation Commission to Build a Healthier America, where we live, learn, work and play can have a greater impact on how long and how well we live than medical care. The app was built off that and motivated by SI PPS’s mission to transform the health of Staten Islanders.
“Many of us have had the experience: We are given a referral or suggestion about where to go for help, but then we never follow through. It can be for a lot of reasons—time, transportation trouble or money. With our teams checking for needs and then instantly connecting people to resources on-the-spot, there is a better chance of people getting the right help when they actually need it,” says Celina Ramsey, Director of Health Literacy, Diversity and Outreach at SI PPS.
“The PPS team spent months assessing and finding the right resources to make the referral process a smooth one,” Ramsey adds.
With this app, patients can expect to have both their medical and social needs addressed seamlessly at a variety of touchpoints on the island. Staten Islanders will be screened at places like the library, the food pantry, where they go for ESL classes or where they see their doctor. Once a need is identified, SI PPS partners will work on linkages and follow each case to ensure all needs are met. The data collected from this survey will be utilized to analyze the prevalent social determinant of health factors in various zip codes in Staten Island and, in collaboration with NYSDOH, implement population health improvement strategies.
An important benefit of the app is to allow for a population level summary of the survey responses of community members, including families. “This census like assessment has never been conducted at this level of detail for factors that are so highly correlated with health outcomes,” according to Joseph Conte, PhD. Executive Director at SI PPS. “It allows for the identification of where programs and resources can be targeted to achieve the highest ROI. What is important is immediately connecting individuals to resources and not leaving a recognized gap in a SDOH.”
The app will be used by all community-based organization, hospital, and select primary care partners. Partners using the new tool have begun rigorous training in care coordination, motivational interviewing, health literacy and SDOH prior to the launch.
“The PPS has done a lot of work to prepare the community-based organizations and primary care practices to launch this project. More than 120 community health workers, navigators, administrators and care managers across 21 organizations have been trained for this SDOH project,” says Sadia Choudhury, MPA, Director of Ambulatory Care Initiatives at SI PPS
“We will be collecting and analyzing data to notice trends in social determinant of health factors across various races, ethnicity, gender, age, etc.,” Choudhury explains. “We believe this program will make a huge impact on Staten Island residents’ health. It will also change their perception of health care.”
Conte concluded, “This program will allow for immediate impact on Staten Island residents’ health but also develop information on where resources and services need to be expanded to prevent the cycle from continuing for themselves and others.”