Most determinants of health are social and not directly amenable to medical treatment. To improve equity, the medical delivery system must partner with social care services, but the institutional bridges are often lacking. Healthy Alliance — originally funded in 2015 by the New York State Department of Health’s Delivery System Reform Incentive Payment program through the Medicaid Section 1115 demonstration waiver — in 2018 developed a social determinants of health network (SDHN) as a regional strategy to provide health-critical social care services in Upstate New York. After more than 4 years of implementation, Healthy Alliance’s SDHN connects community members in need to more than 1,250 services across more than 580 partner organizations spanning 25 counties in New York State. Three managed care organizations have partnered with Healthy Alliance to improve health outcomes through social care services. To date, Healthy Alliance has completed almost 50,000 requests for connections, representing over 28,000 unique community members served. This case study examines those partnerships’ successes, ongoing challenges, and key next steps.

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