As Congress and opinion makers across the country continue to debate potential cuts to Medicaid, a dramatic shift is underway that puts the spotlight on the importance of addressing the social needs of Medicaid recipients. This shift holds the key to sharply improved healthcare for the poor and significant savings for taxpayers.

The experience of SOMOS Community Care, a unique network of more than 2,500 independent Medicaid doctors—most of whom are primary care providers—illustrates the evolution of social care. SOMOS got its start in 2014 as part of an innovative Medicaid program that invited doctors to embrace Value-Based Payment, with doctors’ remuneration tied to the longer-term health of the patient. The healthier the patient, the greater the payment earned by the provider. SOMOS doctors serve more than 1 million African Americans, Asian Americans, and Hispanics living in the inner city.

Further boosting quality of care, SOMOS engaged Community Health Workers (CCCCCCCCCCCCHWs) to assist the doctors by visiting patients’ homes and reporting on the health of the family. Being the eyes and ears of the doctor, the CHWs also take stock of social circumstances, such as poverty, lack of access to nutritious food, lack of education, lack of transportation, and other conditions. Such social factors clearly have an impact on physical and mental health.

With the doctor armed with a comprehensive knowledge of the patient’s circumstances—a knowledge appreciated by the patient—a strong patient-doctor relationship develops that aids the healing process. At this point, the provider is also encouraged to reach out on behalf of the patient to Community-Based Organizations that can respond to the patient’s social needs. The doctor emerges as a community leader and a convener of CBOs. SOMOS doctors achieved significant savings thanks to a 22 percent drop in the number of preventable hospital readmissions and a 35 percent drop in visits to the emergency room.

With funding from the new 1115 Health Equity Reform Waiver, New York State launched a major new social care initiative to improve the health of Medicaid recipients across the state. Twelve Social Care Networks (SCNs) were created, each with a mandate to oversee the provision of social care services to Medicaid recipients in its area. SOMOS was awarded the Bronx region.

Patient care will go well beyond traditional forms of healthcare to include a full spectrum of social services. The Social Care Networks will facilitate doctors’ access to these services to ensure their patients get the social care they need. The SCNs will also directly connect Medicaid members to critical support by contracting with social service providers to provide patients with the necessary resources for housing, nutrition, transportation, and care management. The SCN will facilitate CBOs’ billing.

Research has shown that being mindful of attending to patients’ “health-related social needs” sharply improves health outcomes. The goal is to integrate the work of Community-based Organizations with the services of the primary care and behavioral health care system. It has been estimated that physical health only accounts for about 20 percent of overall health and well-being.

When Social Care Network (SCN) services are reduced, the limitations of hospital care, which cannot provide in-depth social care, come to light. By contrast, thanks to the Social Care Networks, Medicaid recipients with social needs will be connected, via their local doctors’ offices, to vital local resources.

SOMOS Chief Operating Officer Lidia Virgil said: “SOMOS has pioneered social care in underserved communities for many years now. As the largest minority-led network of physicians in New York, we work at the intersection of health care and social care; that is who we are. SOMOS is proud to join with New York State to change the lives of our people in the Bronx.”

The SOMOS Social Care Network serves as a hub where patients, doctors, and CBOs come together for cross-pollination and vital collaboration. As a result, doctors become embedded in the community as local leaders. In the end, it is a win-win-win situation for patients who receive superior care, doctors who benefit from additional earnings through Value-Based Care, and taxpayers who benefit from lower spending due to healthier Medicaid recipients.

Of course, it is vitally important that Medicaid waste and fraud be eliminated, but the program should remain standing. Smart spending is in order. It is most heartening that New York State’s healthcare authorities have come to recognize the importance of social care alongside and in tandem with traditional medical treatment.

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