Social Determinants of Health

The initiatives in this domain support high-need patients and assist providers in providing care by addressing SDoH factors. The efforts include advancing health equity by working with sectors on the factors that influence health, including employment, housing, public safety and food access.

Community Action of Orleans and Genesee Access to Healthcare Program

We collaborated with Community Action of Orleans and Genesee to increase access to healthcare for homeless and housing insecure families in Orleans County through a new program referred to as “Axis of Care.” Housing insecurity was a social determinant of health and a driving force of health inequities.

As part of this collaboration, we provided technical support to ensure the program met its goals. This support included process documentation, consultation on data and analytics, and a program evaluation report.

A health coach at Community Action of Orleans and Genesee connected and coordinated individuals with services, set and tracked goals and outcomes, improved health literacy among those in need, and coordinated transportation to healthcare facilities as needed. The health coach was part of the case management team and collaborated with a peer advocate from Genesee Council on Alcoholism and Substance Abuse (GCASA).

The agency established a telehealth hub in its Eastern Orleans Community Center located in Holley, NY, where community members experiencing homelessness or at risk of homelessness could access healthcare using telehealth services. The agency partnered with Orleans Community Health, Oak Orchard Health, and GCASA on telehealth services and had a mobile clinic onsite. The health coach connected individuals with needed services such as behavioral health treatments and services at the center or at healthcare facilities.

Our Community Partners