Health Leads, Inc.

Social and environmental factors, such as income, education, access to food, housing status, and employment status, can exacerbate health conditions and cause patients to develop more serious—and more expensive—illnesses.

Health Leads has approached these health determinants by creating a system in which providers ask patients about their social and environmental situations, and Health Leads advocates then connect patients to necessary resources and follow up to address challenges. In January 2014, NYHealth convened key stakeholders to gauge their interest in expanding the Health Leads model in New York. The New York City Health and Hospitals Corporation (HHC) agreed to a financial commitment of $750,000 over two years to expand Health Leads services in the primary care settings of three key health centers in New York City. To leverage HHC’s investment, NYHealth awarded Health Leads a grant to support the collection and dissemination of data from the pilot to demonstrate the business value of addressing patients’ resource needs.

Under this grant, Health Leads supported the implementation and assessment of a multisite Health Leads demonstration at HHC, as well as established the business case to financially and operationally integrate patients’ unmet basic resource needs into primary care settings. Specifically, Health Leads collected high-quality data on the unmet basic needs among 1,700 HHC patients, success rates in meeting those needs, and barriers encountered in doing so, which enabled HHC to adjust its clinical decision-making and resource allocation accordingly. Health Leads then evaluated the integration of Health Leads into the primary care delivery system, which provided agency-level data about patients’ successes or failures in gaining access to specific community organizations or types of public benefits. In addition, Health Leads analyzed the data to demonstrate the extent to which meeting the social needs of patients helped to improve health outcomes and/or lower utilization of high-cost health care services, such as hospitalizations and emergency room visits. To disseminate their findings, Health Leads worked with NYHealth to convene health systems and health insurers throughout New York State.