The delivery of healthcare for New York’s Medicaid recipients is currently undergoing a historic transformation. Launched in the winter of 2025 with an initial $500 million investment, a bold state project is finally bridging the gap between traditional medical coverage and the social realities that dictate a patient’s health. This shift recognizes a fundamental truth: a doctor cannot “fix” a patient’s health if they cannot address the social hazards of the patient’s life.

There are nine Social Care Networks (SCNs) tasked with connecting Medicaid beneficiaries and their doctors with Community-Based Organizations (CBOs) that have expertise in specific social care areas. As one of these nine, SOMOS Community Care—a network of over 2,500 independent doctors serving more than one million Medicaid beneficiaries—is proving that the most effective healthcare happens when we treat the whole person.

The process promotes close doctor-patient collaboration, with doctors becoming intimately aware of patients’ social needs, which are known as Health-Related Social Needs (HRSN) and Social Determinants of Health (SDH). Timely intervention on this front prevents illness or delays its worsening, resulting in significant savings.

Our trained Social Care Navigators guide patients through a complex system, ensuring they are effectively linked to CBOs that address the non-clinical social needs—such as housing, food, and transportation—that directly impact on their long-term health and well-being. At present, a lack of access to wholesome nutrition, and affordable housing accounts for the bulk of queries sent to CBOs.

Through this partnership, members gain the tools to identify the social factors that impact their lives, empowering them to transform their environments and their health.

Traditional Medicaid often moves at a glacial pace, burying both patients and providers under a mountain of paperwork. The Social Care Network model ensures that the administration involved in commissioning and paying CBOs is streamlined and transparent. This allows a patient to follow their request for social care in real-time, ensuring accountability and speed.

There is vital long-term potential for the social care initiative. Beyond the delivery of short-term medical and social aid, beneficiaries can improve their lives for the long haul.  For example, when we provide a pantry box to a food insecure family or remove health-threatening mildew from a family home, we are investing in the long-term economic, cultural, and spiritual health of our neighbors. Social care boosts and unleashes human potential, creating a path for more community members to achieve the financial stability necessary to transition toward independent coverage. By investing in high-quality care, we empower individuals to enhance their overall quality of life and achieve lasting wellness, which ultimately creates a more sustainable healthcare system for all New Yorkers.

Medicaid providers in New York State who give their patients social care do so in accordance with the age-old Christian tradition of serving the most vulnerable, the poor, and the sick. Such was the religious duty of Christians from the 4th century onward. In the Middle Ages, most hospitals in Europe were founded and run by the Catholic Church.

The Social Care Network project considers the whole person—body, mind, and soul. That is the essence of healthcare and good citizenship. SOMOS doctors combine faith and medical science to restore patients suffering from social needs to health.

This new mission brings SOMOS Community Care full circle from its founding in 2014, affirming its permanent pursuit of serving our most vulnerable neighbors. By practicing evidence-based, preventive medicine, SOMOS saves New York taxpayers millions of dollars—reducing avoidable emergency room visits and hospitalizations while significantly improving long-term health outcomes for our community members.

These achievements demonstrate that investing in the well-being of underserved populations is a vital contribution to our collective public health. SOMOS has become a national leader in proving the viability and success of Value-Based Care for Medicaid patients. By consistently demonstrating this proof in concept, SOMOS shows that when the system is focused on long-term health outcomes rather than the volume of visits, the entire community benefits. Under this model, superior healthcare is delivered by dedicated doctors, directly enhancing the lives of the most vulnerable, while responsibly stewarding taxpayer funds.

This commitment to the “whole person” is not new. SOMOS instituted early iterations of social care years ago, empowering Community Health Workers to visit patients’ homes and address the environmental and social conditions that impact health.

Today, SOMOS is a cornerstone of the New York healthcare landscape, recognized for its excellence in preventive care and its unwavering support for underserved New Yorkers. Given its track record of clinical and social integration, SOMOS is uniquely prepared to lead as a Social Care Network.

Mario J. Paredes is CEO of SOMOS Community Care, a social care network of more than 2,500 independent providers responsible for reaching out and delivering care to more than 1 million Medicaid patients across New York City