Across New York, a new approach to care is beginning to take hold.
Recent data released by the New York State Department of Health shows the Social Care Network program is expanding—connecting more New York State Medicaid Members to critical services and beginning to demonstrate real impact.
For communities across the Hudson Valley, that progress is not just theoretical. It’s already underway.
Through the leadership of the Hudson Valley Care Coalition (HVCC), the Hudson Valley Social Care Network is helping connect health care with the everyday needs that shape good health and well-being, like housing support, food, and transportation.
A New Model of Care
New York State Medicaid is expanding beyond traditional health care by investing in services that address health-related social needs (HRSNs), because where you live, what you eat, and how you get around all impact your health.
Through regional Social Care Networks, like the Hudson Valley Care Coalition’s Social Care Network, Medicaid Members can now:
- Connect with a social care navigator
- Get screened for unmet needs
- Access services like:
- Housing support
- Nutrition assistance
- Transportation
This isn’t just coordination—it’s a new ecosystem for care, and HVCC is helping bring it to life across the region.
What HVCC and Its Partners Have Achieved So Far
In just over 18 months, several key milestones are already shaping a stronger, more connected system of care in the Hudson Valley:
Closing the Gap Between Health Care and Social Care
HVCC has already screened more than 70,000 Medicaid members and we’re on track to more than double that number in 2026. Across the Hudson Valley we are stabilizing and improving the health and well-being of residents who are struggling with daily living essentials ― and key determinants of health ― like nutritious food, safe housing, and dependable rides to health-related social services.
Building a Regional Network of Partners
HVCC has brought together a growing network of 160+:
- Health care providers
- Behavioral health providers
- Managed care organizations
- Community-based organizations
All aligned around a shared goal: improving health outcomes through coordinated social care.
This network is the foundation of the Social Care Network, ensuring that organizations are working together, not in silos.
Expanding Access to Essential Services
Through HVCC’s Social Care Network, eligible Medicaid Members can now connect to:
- Housing supports such as rent and utility assistance, housing navigation, and home modifications
- Food and nutrition services, including meal support and education
- Transportation to access health-related social needs services
These supports are essential to health—not separate from it.
Introducing Navigation as a Core Service
A key innovation of HVCC’s model is the role of the social care navigator.
Members are no longer left to navigate complex systems on their own. Instead, they can:
- Talk to someone who understands their situation
- Learn what services are available
- Get connected to trusted local providers
This human connection is often what turns awareness into action.
Creating a System That Can Scale
HVCC is helping establish a coordinated, region-wide approach to:
- Screening for unmet social needs
- Making referrals across organizations
- Tracking services and outcomes
This creates a data-informed, scalable system—one that has the potential to improve care not just for individuals, but across entire communities.
Why This Work Matters
For too long, health care and social services have operated separately.
A provider may treat a condition without knowing a patient lacks stable housing.
A community organization may provide food without visibility into broader health needs.
HVCC’s Social Care Network is helping close these gaps.
By connecting providers, community organizations, and members through shared tools and processes, the network is working to:
- Reduce avoidable emergency room visits
- Improve long-term health outcomes
- Make better use of limited resources
It’s a more connected, more efficient, and more human approach to care.
The Opportunity—and the Urgency
This initiative represents a meaningful shift in how care is delivered—but it also comes with a limited window.
With funding tied to a federal waiver timeline, the work happening now is critical to demonstrating:
- The value of addressing social needs
- The effectiveness of coordinated care
- The impact of HVCC’s leadership across the Hudson Valley
The more Members who are screened and connected to services today, the stronger the case for sustaining and expanding this model in the future.
What Comes Next
HVCC and its partners are focused on:
- Expanding awareness across the provider community
- Increasing screenings and referrals
- Strengthening coordination across the network
Most importantly, they are working to ensure that every Medicaid Member who needs support can access it—simply and effectively.
Learn more and take a self-screener to see if you are eligible for free enhanced services.
