Social Determinants of Health (SDH) and Community Based Organizations (CBOs)

SDH are defined as the conditions in which people are born, live, grow, work, and age. These conditions can affect a wide range of health risks and outcomes. The five key domains of SDH include: economic stability, education, social and community context, health and health care, and, neighborhood and built environment. Integrating health and human services to address SDH can have a significant impact on health outcomes. Under Value Based Payment (VBP), VBP Contractors aim to realize savings while achieving quality outcomes by addressing SDH conditions that drive healthcare cost and poor health outcomes.

The purpose of this page is to act as a resource of information for health systems and community–based organizations in relation to the VBP Roadmap requirements. Starting January 1 2018, all VBP Level 2 and 3 arrangements MUST implement, at a minimum, one SDH intervention and contract with at least one Tier 1 community based organization (CBO). Please feel free to email all questions about this requirement to the SDH team at To find out more about the Bureau of SDH, please click here.


Medicaid Redesign Team Supportive Housing: The Medicaid Redesign Team Supportive Housing Initiative is an innovative approach to addressing social determinants of health by investing State only Medicaid dollars into rental subsidy, tenancy services and capital for high-utilizers of Medicaid. The programs work with health systems to create better health outcomes and reduce Medicaid costs.

NY Medicaid Population Health Symposium: The NY Medicaid Population Health Symposium was held November 18–19, 2019. The Symposium convened approximately 800 leaders and stakeholders of New York Medicaid for two days of engaging plenary, breakout, and poster presentations. The event highlighted the collaboration and integration of clinical and social care.

Call for SDH Innovations: Bureau of Social Determinants of Health, launched a new initiative to identify innovative ideas that effectively address the SDH for Medicaid members across New York State. The intent of this initiative was to solicit input from interested parties across the state and around the country. Submitted innovations were reviewed by a team of healthcare experts identified by DOH. The top 9 innovations were highlighted at a DOH sponsored SDH Innovations Summit in NYC.

SDH/CBO Tool Kit

Value Based Payment (VBP) Resource Library

Effective January 1 2018, all new and existing VBP Level 2 and 3 arrangements must include at least one SDH intervention and at least one contract with a Tier 1 Community Based Organization (CBO). This requirement applies to Managed Care Organizations (MCO), Managed Long Term Care (MLTC), and PACE plans with a Level 2 or 3 VBP arrangement. Health plans and VBP contractors have the flexibility to decide on the type of intervention that they implement. The guideline recommends the SDH selection be based on information including but not limited to, SDH screening of individual members, member health goals, the impact of SDH on their health outcomes, as well as an assessment of community needs and resources.

  • This document is the SDH interventions that have been approved by the Department of Health. – 9.24.2019

NEW!!! Updated CBO Directory and Engagement Survey– The New York State Department of Health (DOH) has released a new statewide CBO directory and engagement survey. The survey has been simplified based on feedback from stakeholders and designed to capture information about CBO service provision for the purpose of making connections with MCOs and VBP contractors. This survey is replacing last year´s CBO Survey and is open to all non–profit, CBOs. Information gathered through this new survey will be used to generate a new CBO directory.


Delivery System Reform Incentive Payment (DSRIP) Program

DSRIP Performing Provider Systems (PPS)

Population Health Improvement Program

Medicaid Managed Care Organization Plan Directory

MLTC Plan Directory

VBP University

DRSIP Value Based Payment Resource Library

HEDIS Measures

First 1000 Days on Medicaid Proposals

Provider Contract Guidelines for Article 44 MCOs, IPAs, and ACOs

CBO Planning Grantees– Please contact grantees for available administrative/ support services for CBOs.

Health and Welfare Council of Long Island – Long Island

Hudson Valley Collective for Community Wellness

Healthy Community Alliance – Rest of State
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