Special Projects Fund

Project Title

Improving Care Delivery Through Integration of Primary Care Residents with Community-Based Services

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

September 28, 2016



Western NY






Fostering collaboration among primary care providers and community-based organizations (CBOs) is critical to addressing social determinants of health. Residents at New York State teaching hospitals provide a significant proportion of primary care services to Medicaid consumers and other low-income populations.

Although residents have begun to receive more education and gain experience in enhanced primary care models and population health management, they lack education and experience collaborating with social service CBOs and are not fully integrated into the delivery system reform efforts underway in New York. Additionally, residency programs have not widely incorporated training on social determinants of health into their curricula. To meet the changing needs of the health care landscape and address growing health care disparities, NYHealth awarded a grant to the Greater New York Hospital Association (GNYHA) to create a model program for residents that provides skills and training to recognize and address social determinants of health—those factors outside of the health care system, including housing, education, food security, and racism—that affect how healthy we are.

Under this grant, GNYHA created collaborations between participating residency programs and local CBOs in the Bronx, Staten Island, and Erie County to provide residents with experiential opportunities in CBO settings. GNYHA identified best practices and challenges to implementation and adoption from similar training programs focused on social determinants of health across the country; ascertained the current levels of residents’ engagement and interactions with CBOs; assessed specific community needs in the participating regions; and identified specific CBOs to work with during project implementation. GNYHA also convened an advisory workgroup of key stakeholders to meet throughout the course of the project and help develop the training curriculum. During implementation, GNYHA developed and disseminated a curriculum; engaged residency programs in collaboration with CBOs across the participating three regions; and held a concluding symposium. GNYHA assessed the engagement of participating residency programs with CBOs and measured use of the developed curriculum by residency programs.