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Three-pronged Alliance Addresses Social Determinants of Health


The initiative in Upstate New York links underserved individuals to providers and CBOs.

doctor and patient

Healthy Alliance Independent Practice Association (IPA), Innovative Health Alliance of New York, LLC (IHANY), and Fidelis Care are partnering to provide critical funding and coordination of services to Medicaid members insured by Fidelis Care.

To improve the overall health of vulnerable individuals in Upstate New York, the new partnership will bring together medical providers and community-based organizations (CBOs) to address safe housing, adequate nutrition, employment, and other social factors that impact a person’s health, quality of life, and well-being. The initiative will start on October 1.

Healthy Alliance IPA and IHANY will provide services to Fidelis Care members, focusing on people with at least one chronic health condition who have not had a primary care visit with a provider in more than six months. This initiative aims to link the underserved to primary care, reducing avoidable hospital use and increasing preventive care visits.

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IHANY will connect Fidelis members to the Healthy Alliance network of CBOs, who will link Fidelis members to social, behavioral, and medical care providers through Healthy Together, a closed-loop referral platform powered by HIPAA-compliant Unite Us. CBOs that participate in this program support the needs of vulnerable individuals and will be staffed by community health workers who often are from the neighborhoods they serve.

"Through the Healthy Alliance IPA, we are working to proactively address social determinants of health to improve a person's overall health, while also reducing cost of care,” said Jacob Reider, MD, CEO of Alliance for Better Health. "But this critical work isn't done in isolation. The IPA's success is a byproduct of the partnerships we have built in the Capital Region. We are proud to work with medical providers, managed care organizations like Fidelis Care, and ACOs like IHANY. Together, we can improve our community members' health by addressing social needs before they evolve into medical problems." 

This initiative joins a growing national movement to drive the creation of new models of care with a focus on helping community members and their care teams improve health, instead of just responding when there is a medical problem.

“Aligning with CBOs, which often are the first defense in providing for the underlying needs that lead to poor health, can best be made through partnerships like this,” says IHANY Board President Paul Barbarotto, DO, who practices at Capital Region Family Health Care, a practice of St. Peter's Health Partners Medical Associates. “A person’s health can now be recognized as much more than the medical care individuals seek from doctors and hospitals.” 

“Research clearly shows us that the health of people is largely influenced by factors outside the walls of where they get medical care," says IHANY CEO Leslie Barden. "The United States spends significantly less than other developed nations in addressing social determinants of health including safe housing, adequate nutrition, and psycho-social supports. We believe this is a game changer in improving health for all the people we jointly serve.”

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