Primary Care

Project Title

Integrating Social Care and Community Partnerships into the Primary Care Medical Home to Advance Health Equity

Grant Amount


Priority Area

Primary Care

Date Awarded

November 13, 2023




In Progress


Primary care is often a patient’s first and most regular point of contact with the health care system.

High-quality primary care provides ongoing, relationship-based care that meets the health needs and preferences of individuals, families, and communities, according to the National Academies of Sciences, Engineering, and Medicine. It is a rare “win-win” in health care that improves individual and community health, enhances health equity, and saves money. Despite the benefits, too little is invested in primary care and too many New Yorkers, especially New Yorkers of color, have difficulty getting care when and where they need it. In 2023, NYHealth issued a Request for Proposals (RFP), “Primary Care: Expanding Access and Advancing Racial Health Equity,” to test replicable models to improve the accessibility, quality, and equity of primary care in regions across the State. NYHealth awarded Strong Children Wellness Medical Group (SCW) a grant to participate in this initiative. 

Under this grant, SCW will scale and evaluate a model of pediatric care embedded within community-based organizations designed to address inequities in health outcomes. This innovative model integrates pediatric primary care with mental health, substance use disorder, early head start, and social service programs. It is designed to provide two-generational and trauma-informed support for children and families from historically marginalized communities through care teams comprising clinicians and navigators. SCW will expand its integrated model, originally piloted in the Jamaica and Flushing neighborhoods of Queens, into the Woodside neighborhood, with co-located clinical and social services at The Child Center of New York.  SCW will engage a community advisory board in project design and evaluation to ensure services are culturally and socially responsive and reflective of community need. SCW will evaluate its wraparound model to assess impact—relative to traditional sources of pediatric primary care—on health outcomes such as vaccinations, developmental screenings, behavioral health management, and childhood obesity, among other metrics of engagement and patient experience. It will also create a toolkit to disseminate its pediatric integrated primary care model with health care providers, social service professionals, and policymakers across New York State.  

See a full list of grantees working to expand access to and advance racial health equity in primary care across New York State.