How partnerships with organizations like MHA Orange are helping Medicaid members access food, housing support, and other essentials for better health.
For Odion and Shaniqua, better health didn’t start in a doctor’s office.
It started with food.
Through the Hudson Valley Social Care Network and a partnership with community organization MHA Orange, both Medicaid members were connected to medically tailored meals and other supports designed to address everyday challenges that affect health.
For Odion, the change helped lower dangerously high blood pressure.
For Shaniqua, it meant less stress and more stability for her family.
Their stories show how meeting basic needs can make a powerful difference in people’s health and daily lives.
What the Hudson Valley Social Care Network Does
The Hudson Valley Social Care Network (SCN) connects Medicaid members to services that address everyday needs that affect health. These needs — known as health-related social needs — can include food insecurity, unstable housing, transportation barriers, or difficulty accessing basic resources.
Through the Social Care Network, healthcare providers and community organizations work together to identify these needs and connect members to trusted local services.
Support may include:
• Medically tailored meals and nutrition support
• Housing assistance and home remediation services
• Transportation to social services, job interviews, food pantries
• Care navigation and referrals to community resources
By addressing these everyday challenges, the Social Care Network helps people better manage chronic conditions, reduce stress, and improve overall health.
Watch our interview with Medicaid members Odion and Shaniqua to learn about the real life impact of the Social Care Network.
Start with the Stress
When Darriyia Williams, Team Lead for HVCC’s Social Care Network Navigators, meets someone who is struggling, she doesn’t start with paperwork.
She begins with a simple question.
“What is the stress?”
“A lot of people most times don’t lead with their needs,” Darriyia explains.
“They lead with what stresses them out.”
That shift — from checking boxes to understanding the pressures someone is facing — is the foundation of the Social Care Network.
Because stress affects health.
Food affects health.
Housing affects health.
And when those things are unstable, everything else becomes harder.
Odion: Managing High Blood Pressure with the Right Support
Odion is 52 years old and lives with hypertension, gout, anxiety, and depression.
Before connecting with the Social Care Network, managing his health while working long hours was difficult. Fast food often became the easiest option, and his blood pressure reached dangerous levels.
Through Social Care Network partner MHA Orange, Odion was screened for health-related social needs and connected to medically tailored meals.
“Allison screened me over the phone, and she was very helpful with the program process,” Odion recalls.
Now, nutritious, low-sodium meals arrive directly at his door.
“They deliver right to my door… I can just grab and go. I don’t have to worry about stopping at the store because I go to work at three o’clock in the morning.”
The change has made a real difference.
“My blood pressure’s down now and that’s a good thing… it also helps me financially.”
For Odion, the support has meant:
• Less stress about meals
• Healthier food that supports his medical needs
• A dependable support system
“Everybody that I’ve been dealing with at MHA has helped me a lot and I’m thankful for that.”
Shaniqua: Finding Stability for Herself and Her Children
Shaniqua is 33 and a mother of four children. She is also grieving the loss of her daughter, Angel Grace.
Shaniqua lives with lupus and mental health challenges and has experienced housing instability in the past. Managing her health while caring for her family meant constant stress about everyday necessities.
When she learned she had been approved for Social Care Network food support, she remembers celebrating the news.
“I was jumping for joy,” she says.
“It’s not only a blessing to receive extra food and to receive help — but prepared food has made life so much easier.”
After surgery and with strict dietary restrictions, medically tailored meals have become an essential part of maintaining her health.
“They send me low-sodium foods. It’s amazing. It’s a major help.”
But the biggest change has been peace of mind.
“I’m not worrying anymore. Less worry, less anxiety… things are more organized now.”
— Shaniqua
For someone balancing chronic illness, parenting, work, and grief, that stability is everything.
Why Social Care Matters
Allison Davenport, Program Supervisor at MHA Orange, says the Social Care Network strengthens the work community organizations are already doing.
“It brings together healthcare and community organizations like ours to help people with Medicaid meet their basic needs — nutrition, transportation, housing, and more.”
Before the Social Care Network, many of these supports depended on limited grants or donations.
“The SCN program has given us the opportunity to connect people with resources that weren’t there prior.”
Today, MHA Orange can help members by:
• Screening for health-related social needs
• Connecting people to medically tailored meals
• Supporting home remediation needs
• Coordinating transportation assistance
• Providing ongoing care navigation
And the program continues to grow.
“I see huge potential,” Davenport says. “It’s a constantly growing program.”
Trust Is the Foundation
For Darriyia Williams, trust is the most important ingredient in helping people access support.
“Trust is the number one factor in helping people get the support they need,” she says.
Many Medicaid members have been turned away or left waiting by other systems. Social Care Navigators work to rebuild that trust by staying consistent, following up, and walking alongside members as they access support.
For Darriyia, the work is personal.
“Before I was a care navigator, I was a member of the Social Care Network,” she says.
“I’ve seen it work — and now I’m working so the system can work for others.”
Ecosystem of health and social care for stable living
The Social Care Network isn’t just about delivering meals.
It’s about building what Darriyia calls “an ecosystem of resources that actually get members support.”
When people have access to food, housing, transportation, and other essential supports, their health improves.
For Odion, that meant lowering his blood pressure.
For Shaniqua, it meant less stress and more stability for her family.
For both, it meant something powerful:
Support that shows up when it matters.
Frequently Asked Questions About the Social Care Network
What is the Social Care Network in the Hudson Valley?
The Hudson Valley Social Care Network connects Medicaid members to services that support their health outside of traditional medical care. These services may include food assistance, housing support, transportation help, and other resources that address everyday needs affecting health and wellbeing.
Who can receive help through the Social Care Network?
The Social Care Network serves Medicaid members in the Hudson Valley who may be experiencing challenges such as food insecurity, housing instability, or difficulty accessing transportation. Eligibility is determined through a screening process conducted by healthcare providers or community organizations participating in the network.
What services can the Social Care Network provide?
Depending on eligibility, services may include:
• Medically tailored meals
• Food and nutrition support
• Housing assistance
• Home remediation services
• Transportation to social services, job interviews, food pantries
• Care navigation and referrals to community resources
These services help address everyday factors that influence health.
How do people get connected to the Social Care Network?
Medicaid members may be screened through healthcare providers, hospitals, community organizations, or care managers participating in the Social Care Network. Once screened, a Social Care Navigator helps connect members to services and trusted community partners. Medicaid members can find local community-based SCN partners, get more information or take a self-screener at hudsonvalleycare.org.
Why are food, housing, and transportation important for health?
Research shows that many health outcomes are influenced by factors outside of clinical care. In fact, studies estimate that as much as 80% of health outcomes are driven by social, environmental, and behavioral factors that occur outside the doctor’s office.
Access to nutritious food, stable housing, and reliable transportation can help people manage chronic conditions, reduce stress, and avoid unnecessary hospital visits. Programs like the Social Care Network help address these everyday challenges so individuals can focus on improving their health.
