NYC Health + Hospitals Sees 86% Closed-Loop Rate in First 6 Months

In just the first six months, the partnership between New York City Health + Hospitals and Findhelp resulted in more than 100,000 patients screened for social needs and an 86% closed-loop rate for social care referrals made to CBOs in their Trusted Network. Read our recently-published case study to learn more about this partnership and its effective use of technology and integrations to drive change and improve health outcomes through SDoH assessments and referrals.

Read our case study!



Partnering to improve outcomes

NYC Health + Hospitals is the largest municipal health care system in the nation, serving more than one million New Yorkers annually in more than 70 patient care locations across the city’s five boroughs. To effectively address the large volume of social determinants of health (SDoH) needs at scale, NYC Health + Hospitals implemented Findhelp’s Automated Program Recommendations and Assessment-Informed Launch integrations in Epic, their electronic health record.

These integrations automatically ingest SDoH screening data from Epic into Findhelp.  As a result, staff navigators can now seamlessly provide tailored community-based organization (CBO) recommendations based on an individual patient’s social needs and send closed-loop referrals to local programs.



The challenges

NYC Health + Hospitals is deeply committed to screening for and supporting patients with SDoH needs. Each year, 34% of the health system’s screened patients have at least one active SDoH need, resulting in a consistently high demand for resources. NYC Health + Hospitals believes that a positive screen should always be accompanied by a resource connection. 

  • Meeting Requirements: To meet emerging Joint Commission and CMS regulatory requirements to screen patients in a variety of care settings, the health system needed a way to ensure that all patients in need received recommended resources. 
  • Automated Recommendations: NYC Health + Hospitals needed an efficient and automated way to ensure patients who screen positive after SDoH assessments receive, at minimum, a list of resources to help address their needs.  
  • Closed-Loop Referrals: Navigators needed a quick and easy way to refer patients to trusted community resources, at scale.
  • Self-Navigation: The health system needed a community-facing resource directory to empower patients to independently search for and identify resources (learn more about how Findhelp integrates with Epic’s MyChart patient portal).



Findhelp’s solution

NYC Health + Hospitals knew that in order to sustainably assist patients with social needs at scale, they needed a comprehensive solution to meet these challenges. In 2023, the health system switched from NowPow to using Findhelp as their social care platform and technology solution. To meet their patient population’s high volume of needs, Findhelp worked with NYC Health + Hospitals to develop and deploy two new Epic integrations: Automated Program Recommendations and Assessment-Informed Launch. These integrations greatly automated the process of recommending and referring programs for patients who screened positive on SDoH assessments.


Automated recommendations given to patients with needs

The Automated Program Recommendations integration automatically and bilaterally ingests recommended programs into the patient’s chart and After Visit Summary in Epic, in both English and the patient’s preferred language. 

To do this, Findhelp mapped their service domains to NYC Health + Hospitals’ SDoH assessments in Epic to recommend resources that address the identified needs. The Automated Program Recommendations integration ensures that people with needs receive a curated, recommended list of resources. Program recommendations are automatically filtered based on patient location,  streamlining the workflow for health system navigators. The program recommendations are stored in the patient’s chart in real time, so both the patient and navigator can initiate social care connections during or after the visit.


Supporting efficient referral-making

Assessment-Informed Launch automatically ingests SDoH assessments from Epic and creates a pre-curated list of recommended resources for navigators to electronically refer to.

Whereas Automated Program Recommendations enables programs to be pulled into an After Visit Summary, Assessment-Informed Launch complements this work by enabling navigators to electronically refer patients to resources based on the needs identified in SDoH assessments.



Improving closed-loop rates with Trusted Networks

To engage local community-based organizations (CBOs) in the social care referral process, NYC Health + Hospitals worked with Findhelp to establish a Trusted Network of CBO partners. They partnered with us to build on existing relationships to prioritize specific organizations, provide specialized training, and feature them in their Findhelp platform’s search results. This strong, tight-knit network of priority partners has created positive outcomes for patients by connecting them to the resources they need to thrive.

By aligning community engagement efforts with streamlined navigator workflows through integrations like Assessment- Informed Launch, NYC Health + Hospitals social workers and care navigators referred thousands of patients to trusted resources, resulting in a 99% overall referral response rate and an 86% closed-loop rate*.

*The referral response rate counts all referrals with at least one status update; the closed-loop rate counts all referrals with a definitive outcome, i.e. “Got Help”

Trusted Network data represents Jan 1 to June 30, 2024


The implementation of efficient, tailored workflows also led to staff engagement and support for the platform as part of NYC Health + Hospitals’ broader health equity strategy.



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