Success Stories

Social Determinants of Health (SDOH): Success Stories of Clients Receiving Intervention

Food Insecurity

Island Voice:
One of the clients screened for SDOH by Island Voice mentioned that she always runs out of food before the end of the month. The navigator provided her with information and connected her with the pantries located on Staten Island that would be convenient for her. The navigator called her back two weeks later. The client said that the pantries filled in the gap and she had enough food to get her through the end of the month.
Jewish Community Center of Staten Island (JCC):
The JCC hosts the only Kosher food pantry on Staten Island. They help many clients with food insecurity, but one family stands out. This family needed assistance with food, so the JCC did an intake for their food pantry. The family now comes weekly to get packages of food. They also had a son in high school who was struggling to find a summer job. The JCC referred him to their camp director, and he became a summer camp counselor. Having a means of getting food and having their son make some money alleviated much of the pressure the family was feeling.

El Centro del lnmigrante:
A client was inquiring about El Centro’s services and the navigator took the opportunity to conduct a SDOH survey. They listened to this young gentleman attentively as he verbalized his present situation. Although the navigator was able to assess other needs, the client only prioritized the food pantry referral. On the follow-up call to ensure he was able to connect with needed services, he stated that he had gone to the El Centro Food Pantry. He noted how much

the food pantry helped and that he will continue to attend as needed. The navigator also made sure he applied for SNAP benefits. The client expressed his appreciation not only for the food provided but also for the listening ear. “Of course, I remember you,” the client stated during the follow up call. This proves once again that empathy and compassion go a long way.

Make the Road New York:
The client is a Make the Road New York member and a survivor of Hurricane Sandy. The hurricane had affected his home and employment. Years later he appeared at the MRNY office with another unfortunate story. Overnight the building where he worked had burned down and he became unemployed and uninsured. Through the SDOH project, they were also able to connect him with information about food pantries in his area. When they followed up with him, he expressed gratitude and mentioned he got great service at the food pantry and will continue going there.

Staten Island Mental Health Society:
After completing the SDOH screening with a 16-year-old male client and his mother, it was determined that they experienced food insecurity. The Care Manager provided the parent with a City Harvest Mobile Market referral card to go pick up free and fresh produce for their family twice a month. The care manager also provided the client with the list of local food pantries and soup kitchens. When the care manager followed up, the mother reported that she had attended the most recent mobile market and was utilizing the resources for her family. The client is also enrolled in Health Homes to address any ongoing needs.


Richmond University Medical Center
The navigator interviewed a client on the SDOH screening tool and asked her if she needed any services that RUMC could provide for her family. The client said yes and began to cry. She only spoke Spanish. When the navigator asked her what was wrong, she said, 11 I have nothing; no family, no clothing. 11 The client has 2 children. One child was 6-years-old and the other was 8-months-old. The navigator comforted the client assuring she can help her with the situation. The navigator then called Project Hospitality, Salvation Army, and Cross Road Foundation. The navigator also referred the client to the RUMC food pantry.

The navigator was able to arrange for the client to receive the following through the referrals: diapers, bottles for the baby, clothing for both children and mom, and a stroller.

The navigator went beyond that; She drove to the client’s home to give her everything that she was able to arrange.


Staten Island University Hospital {SIUH):
A 22-year-old African American female client was engaged by a navigator at the outpatient mental health clinic through the SDOH assessment. The client expressed gratitude for the opportunity to express her concern and feelings regarding her current housing situation.

The client recently started to receive mental health treatment at a behavioral health clinic after the inpatient admission. Her mother has a chronic medical condition, which is well-managed but still relies heavily on the client to handle numerous family responsibilities making her often feel overwhelmed. The client’s family is having an issue with mold in her house. The navigator referred her to Project Hospitality for housing resources. She expressed feeling empowered through SDOH engagement.


Community Health Center of Richmond:
While conducting the SDOH screening, the client stated that she needed work

and transportation assistance. She shared that she walks everywhere she goes with her baby in a stroller. The navigator was able to connect the client with appropriate resources immediately. The navigator referred this client to SI Workforce 1 Career Center and informed her case manager at Community Health Center of Richmond of her transportation issues since CHCR can provide metro cards to their patients.


The navigator followed up with the client two weeks later and she confirmed she went to SI Workforce where she is receiving help on resume preparation and job seeking strategies. The client also received a metro card from Community Health Center of Richmond. A few weeks later, the client went for a focus group. She had a smile on her face and looked as if a weight was lifted off her shoulders. The client is still looking for work, but she is being provided more support and resources by her health care team as a unit in Community Health Center of Richmond and from the community resources with which she was linked.


Make the Road New York {MRNY):
The client has a young daughter who was born with a medical condition that affects her mobility. She struggles taking her daughter to the doctor because her specialist is in another borough. When the navigator conducted the SDOH survey with her, they realized that she needed help with transportation to get around with her daughter. They helped her apply for Access­A-Ride. MRNY received great news from the family that the daughter was approved for Access-A-Ride, which is a great relief.

Staten Island University Hospital (SIUH):
A 28-year-old male client with a history of mental health conditions was referred to Health Solutions for care coordination. The client’s main concern was having limited social support and limited access to community resources. Upon connection to Northwell Health Solutions through the SDOH project engagement, the client started to receive car service transportation to his medical appointments. The client meets with the care coordinator regularly and is currently working on additional issues, such as housing and applying for additional public assistance. The client is satisfied with the SDOH and care coordination services.

Safety & Legal

Richmond University Medical Center (RUMC):
A client came into Richmond University Medical Center Emergency Room where the navigator screened her for the SDOH factors. The client originally came to the Emergency Room for a medical issue but after becoming comfortable with the navigator, the client opened up about a previous domestic violence incident that she had experienced. She had a case worker with another organization who did not communicate with her for four months. The navigator was able to reach the client’s case worker and resumed the connection. The client also requested assistance with getting a behavioral health doctor. When the navigator called to make a behavioral health appointment with Community Health Acton of Staten Island (CHASI), the CHASI case worker offered further assistance for the client. The navigator followed up with the client three weeks later. The client reported that she met with the CHASI case worker and was doing much better.


Staten Island Mental Health Society:
After completing the SDOH screening with a 14-year-old female and her mother, the client’s need for socialization/recreational activities was identified. The care manager provided information about the New York Public Library youth programs to address the need. Upon follow up, the mother was

happy to report that her daughter was now attending the New York Public Library youth programs. No other needs were reported.

Medical Appointments: Primary Care & Behavioral Health

Community Health Action of Staten Island Story:
A client stated on the SDOH screening that he was not happy with the mental health clinic he was currently attending. Since the navigator is stationed at the RUMC mental health clinic once a week, the client was referred there. On the day of his appointment, the navigator met him there and helped him navigate through the evaluation and referral process. He called several days later stating that he was comfortable opening up to his therapist and appreciated the navigator’s help. His mother also called thanking the navigator for assisting her son on the day of his appointment.

Silver Lake Special Services:
The client came in and the SDOH screening was done. In doing so, the client reported that he not only did not have a primary care physician, but also has not seen a dentist in years. The client reported having a tooth he felt was decaying. The client was referred to a primary care physician and a dentist who determined his decaying tooth was causing an infection in his gums that had entered his blood stream. After following up, the navigator learned that with the referral to the dentist and a primary care physician, the client was able to receive the correct treatment.