A Vision 40 Years in the Making
For Cathy Clancy, the effort to connect health and social care is more than a new initiative, it’s a lifelong mission.
“I’ve been working on this for decades,” she says. “The need for social service agencies to connect with the healthcare ecosystem in a more effective way has always been there. It’s just really hard to do.”
Clancy’s relationship with Hudson Valley Care Coalition (HVCC) runs deep. As one of the original architects of its Health Home, she helped shape the organization’s early framework for coordinating care across behavioral health, primary care, and community supports. Today, as board chair of HVCC, the lead entity for the Hudson Valley’s Social Care Network (SCN), she sees the work as both a natural evolution and a bold next step.
Breaking Down Barriers Between Health and Social Care
Through New York State’s 1115 Medicaid Waiver, Social Care Networks are designed to help individuals access supports that directly impact health, such as food, housing, and transportation.
Clancy sees the promise in that vision but knows the path to implementation is complex. “Every part of the system—providers, payers, and community-based organizations—has its own culture, technology, and language,” she explains. “Bringing them together requires not just new tools, but a complete culture shift.”
She believes HVCC’s regional approach offers a powerful model. By partnering with more than 150 community-based and governmental organizations, HVCC’s Social Care Network creates a single point of connection for Medicaid members who need help addressing their health-related social needs.
“If we’re serious about affordability and access, we have to organize systems that connect people to the supports that keep them well,” says Clancy. “That’s the only way to make health care sustainable.”
What’s Holding Providers Back—and How to Fix It
Despite enthusiasm for the SCN’s mission, Clancy acknowledges that adoption can be challenging. Many providers and community agencies are still learning how to incorporate new screening and navigation processes into existing workflows.
“The health system has been built around per-visit payments,” she notes. “Now we’re asking organizations to think differently—to look at long-term engagement, care coordination, and outcomes. That’s a big change for anyone, especially smaller community agencies.”
She also points to the need for shared data and technology systems that seamlessly connect payers, providers, and CBOs. “Until we can see, in real time, that a housing referral has been received and acted on, it’s going to be hard for everyone to trust that the system works,” Clancy says.
Looking Ahead: A More Integrated Future for Medicaid and Community Health
Even with these challenges, Clancy remains optimistic. “This is a giant step forward,” she emphasizes. “It’s not as simple as flipping a switch—it’s about culture change and truly understanding our communities. But if we can keep these Social Care Networks moving forward, we’ll help mature the entire healthcare ecosystem.”
Clancy believes the key is collaboration: aligning state agencies, payers, health systems, and community organizations around shared data, accountability, and purpose. “When we connect health care and social care in a meaningful way,” she says, “we’re not just improving outcomes—we’re building healthier, more resilient communities.”
FAQ
How is HVCC involved in New York’s Social Care Network initiative?
Hudson Valley Care Coalition serves as the lead entity for the Hudson Valley’s Social Care Network, coordinating partnerships among healthcare providers, managed care organizations, and community-based organizations to connect Medicaid members with food, housing, and transportation supports.
Why is integrating health and social care so important?
Research shows that up to 80% of health outcomes are influenced by social factors such as access to nutritious food, safe housing, and reliable transportation. By addressing these needs, Social Care Networks help improve overall wellbeing while reducing healthcare costs.
What challenges do providers face in participating in the SCN?
Many providers are adapting to new workflows, reimbursement models, and data-sharing platforms. HVCC offers an SCN partner toolkit, training, technical assistance, and partnerships to help organizations integrate SCN screenings and navigation into daily operations.
How can community organizations join the SCN?
Community-based organizations that provide housing, food, or transportation services can contact Hudson Valley Care Coalition to learn how to become contracted SCN partners and receive reimbursement for services delivered to Medicaid members.
About the Author
Cathy Clancy is Chief Operations Officer at MVP Health Care and serves as Board Chair of the Hudson Valley Care Coalition. With more than 40 years of experience in healthcare administration, policy, and community development, she has led statewide initiatives focused on health equity, system integration, and quality improvement. Clancy’s leadership continues to guide HVCC’s efforts to bridge health and social care for the benefit of Medicaid members and the Hudson Valley community.
