Primary Care

Grantee Name

Maimonides Medical Center

Funding Area

Primary Care

Publication Date

January 2019

Grant Amount


Grant Date:

October 2013–November 2017


New York State’s adoption of Health and Recovery Plans (HARPs) in 2014 aimed to manage physical health, mental health, and substance use services in an integrated way for adults with significant behavioral health needs. 

Under a 2013 grant, NYHealth awarded Maimonides Medical Center a grant to assess the costs and benefits of social services and to incorporate them into a comprehensive total-cost-of-care model. However, New York State’s adoption of HARPs vacated the need for the project’s initial premise. Recognizing the need to make smart investments in social services for patients, Maimonides redesigned the project. The project team studied a sample of 600 patients engaged in at least nine months of consistent care management through the Brooklyn Health Home program. They collected first-hand patient data to assess the extent to which social services with a demonstrated impact on health influenced health care outcomes, as well as to identify the best opportunities for future investments in social services.

Outcomes and Lessons Learned

  • Conducted a pre-post analysis of the impact of six social services: housing, food assistance, income support (cash assistance), legal services, peer support, and vocational training.
  • Found that five of the six social services assessed—housing, food assistance, income assistance, legal services, and vocational training interventions—were associated with some reductions in health care utilization and costs.
  • Created a methodology for social service reinvestment based on the study’s findings.

See the study brief for more details and topics for further exploration in investigations of social services receipt on health care utilization and cost.

See the full NYHealth report here.

Co-Funding and Additional Funds Leveraged: N/A