Targeting Social Needs Among New York’s Medicaid Population

December 28, 2022

Evolent collaborates with a Medicaid plan and nonprofit social services agency to support whole-person health.



It’s no secret that the conditions in which people live can have an outsize influence on their health outcomes.  

Growing awareness of the impact of social determinants of health, such as access to safe housing, healthy food and transportation, has spurred greater interest for health care organizations, particularly Medicaid plans, to begin addressing them. Yet, recognizing needs and fulfilling them are two different things. Blanket approaches, such as offering transportation vouchers to all members, may be ineffective and inefficient uses of precious health plan resources. Plans need deliberate approaches to identify individual members’ needs and then effectively target them with the right social supports that allow them to better manage their health. 

A Collaborative Program

Since May 2021, Evolent Health Services has been helping our Medicaid partner, SOMOS, to operate a program that addresses individual members’ social needs in the larger context of their health challenges. SOMOS, a network of more than 2,500 providers who have come together to ensure better health care for Medicaid members in New York City, has also engaged a nonprofit social services agency, R.A.I.N. Total Care, Inc., to connect members to the support they need. SOMOS is among the few Medicaid programs in the state of New York to directly address social determinants. 

As part of the program, Evolent Care Advisors—which already works with members to manage their overall health problems—also screens those members about their social needs and living conditions. For example: Are they having difficulty paying their rent? Are they having trouble with rodents? Do they need assistance with food access or quality? Are they worried about where their next meal is coming from?

Once the Care Advisors identify social needs, they refer the case to R.A.I.N., which reaches out to the member to further understand their situation and identify resources that can help. There are dozens of ways they can assist, from helping members fill out applications for public housing, to obtaining housing assessments or getting members placed in meal programs such as Meals on Wheels.  


In its first 15 months, the program served nearly 900 SOMOS members, who received more than 1,100 interventions to address their social needs. Examples:

  • A member who needed a specialized diet following a kidney transplant told her Evolent Care Advisor that she was having trouble affording food. The patient’s case was referred to R.A.I.N., who helped her obtain SNAP benefits. Better access to healthy foods, together with education from the Care Advisor, helped the patient better care for her kidneys.
  • A member had been diagnosed with asthma as well as an orthopedic condition that made her a high fall risk. R.A.I.N. helped her mother to obtain transportation assistance, gain approval for SNAP food assistance and apply for public housing. Meanwhile, the Care Advisor educated the mother on fall precautions, healthy eating, managing asthma medications and symptoms, and more. The patient remained free of falls or emergency department visits throughout her program. 


Ready for What’s Ahead

Medicaid plans are ramping up programs to address social determinants of health. After seeing the results of early pilot programs, more states are mandating that plans take on this challenge and are holding them accountable for results. Leveraging what we have learned so far from this collaborative effort, SOMOS, Evolent and R.A.I.N. are well-prepared for this long-awaited improvement in how we support patients with whole-person care. 

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