A new data sharing effort is underway in New York to facilitate connections to social services for Medicaid beneficiaries.
The partners involved are Public Health Solutions (PHS), New York City’s largest public health nonprofit; Hyphen, a health tech company; and the Coalition of Asian-American IPA (CAIPA), representing independent docs that serve Asian Americans. Their integration aims to link more Medicaid beneficiaries to social services through the 1115 waiver.
Hyphen, already an interoperability and analytics partner for PHS, now connects more than 300 CAIPA providers to PHS’ community resource network. The network, WholeYouNYC, serves more than 3 million Medicaid members in the city. The platform connects those in need to community resources and Medicaid-funded services. The underlying tech supporting referrals in the partnership is the platform Unite Us, which CAIPA care navigators use to connect patients to services.
“This is a really historic moment in healthcare,” Zachariah Hennessey, chief strategy officer and executive vice president of PHS’ WholeYouNYC, told Fierce Healthcare in an exclusive interview. “We are the leaders building the infrastructure that supports that delivery network.”
Hyphen gets information on screenings from any organization, receiving data from Unite Us, the state health information exchange Healthix and managed care organizations. This interoperability is made possible in part by a mandate from the Centers for Medicare & Medicaid Services. Hyphen will also make screening data available to PHS and CAIPA in a population health management solution in early 2026.
Providers often face challenges screening for social needs because these screenings may be disconnected from their clinical workflows, Hennessey explained. They may also lack multilingual options. Hyphen streamlines this by embedding social needs screenings directly into CAIPA providers’ EHRs, then relaying the results to WholeYouNYC and care navigators.
More than 300 CAIPA-affiliated providers, including primary care docs and pediatricians, can now screen patients for social needs in English, Chinese, Bengali and Korean.
“We take it for granted that we can access any restaurant or food service provider via technology,” Hennessey said, “but, currently, there is no coordinated, technology-enabled access to the social safety net for healthcare.”
A benefit of the partnership is that patients already working with CAIPA navigators could continue to do so. “That trusted relationship doesn't get disrupted. The technology is really supporting the human connections and reinforcing the established relationships that patients already have,” Hennessey said.
“A lot of the population in New York City really need the hyper-local, community-based infrastructure for them to access care and services like [these],” echoed Eliza Ng, M.D., chief medical officer at CAIPA.
The 1115 waiver, approved in 2024, increased coverage for certain social services. Also among the waiver’s goals is to set up social care networks to help manage screening, verifying the eligibility of members and generating a social care plan for them. PHS, CAIPA and Hyphen are executing on that exact reform.
PHS is prioritizing smaller independent providers, community health centers and safety net providers when identifying screening gaps. Doctors are notified when their patients are eligible for a screening. “It’s our duty to make sure that the people who need them the most get them first,” Hennessey noted.
CAIPA care navigators try to engage patients within five days of a screening and have access to a closed-loop referral system so they can know when a patient receives a service.
“Our vision is to integrate health-related social needs as part of clinical care for perpetuity,” Ng said.