The fast-moving, far-reaching novel coronavirus is unlike any public health crisis that New Yorkers have experienced in their lifetimes—and yet it follows a well-trodden pathway that connects social conditions to health. New York City Health + Hospitals (NYC H+H) is the city’s single largest healthcare provider to Medicaid and uninsured patients. During the spring of 2020, NYC H+H served close to 20% of patients hospitalized for coronavirus disease 2019 (COVID-19) in New York City. The demographics of NYC H+H’s COVID-19 patients largely reflect NYC H+H’s typical patient population. The majority are low-income and identify as Black or Latino, and many are immigrants. Citywide, Black and Latino New Yorkers passed away from COVID-19 at double the age-adjusted rate of White and Asian New Yorkers,¹ exposing the effects of structural inequity on the health of historically marginalized communities.

Beyond the tragic direct effects of COVID-19 is a “shadow” pandemic related to the social determinants of health. “Upstream” social factors, such as food, housing, and financial security, sometimes follow long and complex pathways to influence health outcomes. In the era of COVID-19, many of those pathways have become short and direct.

There are numerous inter-related reasons for this. Four out of five minimum wage earners in New York City are people of color employed in sectors such as grocery stores, restaurants, and health services, where maintaining social distance is impossible.² In addition, stay-at-home orders create economic dislocation, which has cascading effects on health outcomes—by diminishing food security, housing stability, and financial security. For immigrants, problems can be amplified. Nearly 70% of New Yorkers living in crowded dwellings, where it is harder to isolate, are immigrants.³ Many immigrants will not qualify for government benefits because of their immigration status, or may forgo government benefits out of fear of how the public charge rule may affect them, since that rule can be used to deny immigrants visas due to lack of economic resources.

For health systems, addressing patients’ social needs during the pandemic requires developing strategies to counteract the reverberating effects of COVID-19.⁴ To meet the intensified social needs of our patients, NYC H+H built on an existing foundation that incorporates social needs into patient care. NYC H+H began this effort at the turn of the nineteenth century when Bellevue Hospital launched its Social Work department. In more recent years, NYC H+H developed a systematic approach to addressing patients’ social needs through large-scale interventions in four key areas: food insecurity, housing, legal resources, and income support. For example, NYC H+H regularly screens primary care patients for social needs, provides medical-legal services through an on-site partnership with the New York Legal Assistance Group, and provides tax assistance preparation at a handful of clinical sites. When the COVID-19 crisis hit, NYC H+H staff reassessed patient need and shifted its efforts and resources toward the most critical needs, expanding its approach within the operating frameworks of its foundational programs.

A key step was to determine the nature of patients’ social needs in the context of the COVID-19 crisis—and to develop a plan to meet those needs that allowed for flexibility and rapid dispersion given anticipated changes in NYC H+H’s approach to care delivery. One anticipated change was a decrease in in-person visits, which limited access to social services provided on-site, for example. Social workers and other clinicians advised on the greatest needs, guided the operationalization of plans, and, along with care coordinators, case managers, and community health workers, executed plans to get services to patients and their families.

ADDRESSING PATIENTS’ NON-MEDICAL NEEDS IN THE ERA OF COVID-19

The influx of patients with COVID-19 began to escalate quickly in March, rising from 38 NYC H+H patients having tested positive for COVID-19 on March 15th to 6,746 patients by March 31st. This made it clear that a concentrated proportion of NYC H+H’s inpatient population would soon need care for this disease. NYC H+H’s investment to address social determinants of health prior to the COVID-19 pandemic laid the groundwork to quickly address the needs of its patient population during an emergency. The Social Determinants of Health team based in NYC H+H’s central office was already in place to build interventions and bidirectionally communicate with frontline staff working to address patients’ unmet social needs across NYC H+H’s hospitals and community-based clinics. The team solicited insight from social work directors about the needs of patients hospitalized and isolating at home due to COVID-19. Food, housing, and income support were identified as immediate priorities.

Because New York City shut down almost overnight, it was difficult and time consuming for staff to access resources from their usual social service partners, many of which had suspended services, shifted hours of operation, or were transitioning from in-person to telephonic services. In addition, new resources were emerging. The Social Determinants of Health team created a short list of curated, high-yield social resources. For example, the team shared guidance about New York State’s new paid family leave policy and tips on how to apply for it. The list was designed to be relevant to social workers, who are expert at navigating social services, while easy to follow for doctors and nurses who may not typically promote social services in their day-to-day practice. The team worked with NowPow, a community referral platform, to update its comprehensive inventory of organizations in New York City to reflect current operational status. NowPow used web research, social media research, email and/or made calls to over 5,500 local nonprofit and public organizations asking about operational status. NowPow then tagged listings with updated operational information so NYC H+H users would know which organizations were still operating and if the organizations were offering phone, virtual, delivery, or pick-up services.

FOOD

A prime concern for many NYC H+H patients is access to food. Unequal access to healthy food is a byproduct of the structural inequities that exist, particularly in communities of color.⁵ Prior to COVID-19, food insecurity was consistently identified by patients in structured social needs screening programs as a key need. The COVID-19 crisis exacerbated this need due to the loss of income, social isolation, and closures of public schools and senior centers where individuals had reliably accessed meals.

To address the food crisis, NYC H+H built a team to reach out to patients to connect them to food resources. The team consisted of workers who were underutilized when normal operations ceased and included NYC H+H community health and social workers and employees of community-based organizations (CBOs) that are contracted by NYC H+H. Community health workers typically serve patients with high-risk medical conditions to help them address complex social and medical needs and connect patients to primary care. CBO partners typically provide on-site Supplemental Nutrition Assistance Program (SNAP) benefit enrollment and connection to other food resources.

To identify patients in need of food, NYC H+H staff used its electronic medical record system to create lists of adult patients who tested positive for COVID-19 and were discharged following inpatient treatment at NYC H+H. Staff also developed a toolkit of workflows and scripts to be used by the food outreach team. To ensure that patients received clear, cohesive post-discharge care, the food outreach team coordinated their efforts with other NYC H+H teams, such as NYC H+H’s certified health home agency and primary care physicians whose patients were hospitalized.

After 1.5 to 3 hours of training, team members began making outreach calls. Team members helped patients enroll in the SNAP, navigate food pantries, and enroll in a new temporary meal delivery program put in place by a mayoral appointed “food czar” to address food insecurity during the COVID-19 crisis. Team members also asked about emotional well-being and addressed other needs that patients raised (e.g. details about the moratorium on evictions). Low supervisor-to-staff ratios were implemented and ongoing supervision was provided to support team members navigating challenging logistical and emotional conversations with patients.

Of the approximate one thousand outreach calls made in the first week, more than half of all targeted patients were reached, and one quarter were provided with assistance to secure food. Moreover, the development of the program generated tools, such as telephone scripts, trainings, and resource lists, that can be replicated to meet the food needs of other targeted groups of NYC H+H patients in a holistic and thoughtful way after the pandemic. These tools were already adapted by a social needs resource team operating under the Test and Trace program launched by New York City government in early June.

HOUSING

Homelessness and housing instability pose significant challenges to addressing the COVID-19 crisis in New York City. Residing in shelters, streets, or overcrowded dwellings makes social distancing measures difficult to implement and exposes homeless individuals to infection with COVID-19.⁶ Because homeless individuals suffer from a high burden of chronic diseases, they are particularly vulnerable to complications from COVID-19.⁷

In New York City, more than 55,000 individuals sleep in the shelter system nightly, many in congregate settings with dorm-like sleeping, bathing and eating spaces.⁸ NYC H+H serves approximately 45,000 homeless patients in a year. With the onset of the pandemic, NYC H+H collaborated closely with the New York City Department of Homeless Services to develop protocols for moving infected patients from the shelter system to the hospital or to sites where patients could be isolated and receive telemedicine. NYC H+H also created a number of hotel beds with varying levels of on-site medical care for homeless patients requiring care but not hospitalization for COVID-19 infection.

In addition, H+H has a long-standing partnership with the New York Legal Assistance Group’s (NYLAG) LegalHealth division to provide free, confidential services to patients, which can be used to help patients with housing-related legal issues, particularly eviction.⁹ Traditionally, NYLAG attorneys are on-site and referrals are coordinated locally by hospital staff. Due to limits on the presence of non-essential staff at hospitals during the COVID-19 crisis, NYLAG attorneys transitioned to telecommuting—and one centralized system for scheduling was established to ensure that demand for legal counsel was available on a first come, first service basis for all NYC H+H patients through telephone-based appointments.

FINANCIAL ASSISTANCE

NYC H+H provides every patient with healthcare regardless of their ability to pay, which means that money is not a barrier to care. However, clinicians reported hearing from patients struggling to protect their health due to loss of income. One doctor recounted the story of a patient who called describing symptoms of COVID-19. The patient herself was not hospitalized, though her husband was in intensive care on a respirator. At the time, testing was available only for those seeking hospital care. Still, the patient was considering returning to work cleaning houses the next day because she needed the income to support her husband and son. Many patients hospitalized for COVID-19 expressed similar concerns about their inability to cover rent, phone, food, and energy bills. Many patients had limited eligibility for federal benefits due to immigration status.

To address some of their financial needs, Robin Hood, an anti-poverty foundation, supported a novel cash assistance fund, the Emergency Financial Hardship Grant, for up to 500 low-income COVID-19 patients hospitalized at NYC H+H. The program, run by New York Disaster Interfaith Services, provides grants of $1000 per patient, without restrictions on how funds are spent. Screening of patients is conducted by social workers and care coordinators providing support for patients hospitalized for COVID-19. Patients who are undocumented or are ineligible for alternative financial benefits, including federal stimulus checks, are prioritized for a referral into the program. The goal is to provide a quick burst of funds to support patients’ basic health, financial, and social needs in their recovery from COVID-19.

CHALLENGES

One of our most difficult challenges has been securing financial assistance for families to defray the expenses associated with burials. The number of New Yorkers who have died due to COVID-19 is tragic, and many families have informed NYC H+H clinicians that they cannot cover burial costs. Existing programs that cover burial costs are limited. Many programs require that families cover the costs upfront and seek reimbursement later, that both the decedent and the applicant have social security numbers, and that the decedent have no assets.

Another challenge lies in the complexity of accessing cash benefits like stimulus funding and unemployment benefits. Some benefits require filing a bank account with the Internal Revenue Services, having filed taxes last year, and successfully navigating onerous paperwork. Moreover, these financial benefits are not available to undocumented immigrants, despite the fact that many pay taxes, leaving a large swath of our patient population without a safety net and limited paths towards legal permanent residency and citizenship status.

The COVID-19 crisis stalled many standard operations at NYC H+H, including a plan to integrate NowPow into its electronic health record system and to streamline access to medical-legal services. However, H+H was able to quickly implement new programs to address social needs because of its investments in systems and social work departments prior to the COVID-19 crisis. The partnership with NowPow was leveraged to provide up-to-date information about social services that are relevant and matched to patient needs, for example. Recalibrating these existing resources allowed H+H to address the needs of COVID-19 patients during a significant public health crisis. This crisis also opened up unique opportunities to build new unconventional models, such as the Emergency Financial Hardship Grant.

LESSONS LEARNED

There are a number of relevant lessons from NYC H+H’s experience addressing the first wave of the COVID-19 pandemic that can be applied to other health systems. NYC H+H strived to offer targeted, convenient resources to meet the social needs of its most vulnerable patients. For instance, food outreach calls were successful because patients had minimal burden other than fielding a call and accepting assistance. Outreach was well-received in part because it included human-to-human connection at a time when it was scarce. Further, NYC H+H was able to rely on its well trained and empathetic staff of social and community health workers, a critical resource during a time of crisis.

The social and economic crisis ignited by the COVID-19 pandemic will continue to evolve. Mitigating the damage of COVID-19 on patients may require further adjustments to existing approaches to address social needs, such as strengthening eviction prevention resources, addressing trauma through mental health support, and securing philanthropic support to fill gaps in financial assistance programs like burial assistance. While we continue to prioritize the social needs of patients with COVID-19 and their families, we must also develop robust policy approaches to address the “shadow” pandemic affecting millions more.

For many New Yorkers, the solution to the COVID-19 crisis is not simply a vaccine or treatment, but an end to structural inequities that have put an unfair burden of COVID-19 on communities of color. Strategies like universal healthcare, increases to the federal minimum wage and poverty threshold, and investments in universal childcare, pre-K programs, and public schools are needed, and they require broad-based political coalitions. As health systems strive to meet the medical and social needs of their patients, policymakers, public health leaders, and community leaders should demand and execute strategies to remove the inequity underlying our social and economic systems, which exacerbates crises like COVID-19.

ACKNOWLEDGMENTS

The authors would like to thank the following team members for their leadership and persistence in meeting patient needs, including Evelyn Perdomo and Janine Knudsen from H+H; Marjorie Momplaisir-Ellis and Savitha Mani from OneCity Health; Veyom Bahl and Jon Goldman from the Robin Hood Foundation; Randye Retkin, Julie Brandfield, and Beth Breslin from NYLAG; Rachel Kohler, Stacy Lindau, Catherine Ma, Caroline Sudduth from NowPow; and Arielle Burlett, Mireille Mclean, Julieta Velasco, and Ralitsa-Kona Kalfas from Public Health Solutions; Chris Leto and Colin Edgar from Riseboro. [Published online July 16, 2020.]

NOTES

• 1New York City Department of Health and Mental Hygiene. Age-adjusted rates of lab-confirmed COVID-19 non hospitalized cases, estimated non-fatal hospitalized cases, and total persons known to have died (lab-confirmed and probable) per 100,000 by race/ethnicity group [Internet]. New York (NY): DOH; [cited 2020 May 3]. Available from: https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-deaths-race-ethnicity-04302020-1.pdf Google Scholar Google Scholar
• 2Fiscal Policy Institute. Immigrant Workers and the Minimum Wage in New York City [Internet]. New York (NY): The Institute; [cited 2020 May 3]. Available from: http://www.fiscalpolicy.org/ImmigrantWorkers&MinimumWage.pdf Google Scholar Google Scholar
• 3Office of New York City Comptroller. NYC Housing Brief: Hidden Households [Internet]. New York (NY): The Office; 2015 Oct [cited 2020 May 3]. Available from: https://comptroller.nyc.gov/wp-content/uploads/documents/Hidden_Households.pdf Google Scholar Google Scholar
• 4Wadhera RK, Wadhera P, Gaba P, Figueroa JF, Joynt Maddox KE, Yeh RWet al. Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs. JAMA. 2020;323(21):2192–95. Crossref, Google Scholar , Google Scholar
• 5Kwate NO, Loh JM, White K, Saldana N. Retail redlining in New York City: racialized access to day-to-day retail resources. J Urban Health. 2013;90(4):632–652. Crossref, Medline, Google Scholar , Google Scholar
• 6Mosites E, Parker EM, Clarke KE, Gaeta JM, Baggett TP, Imbert Eet al. Assessment of SARS-CoV-2 Infection Prevalence in Homeless Shelters—Four U.S. Cities, March 27–April 15, 2020. MMWR Morb Mortal Wkly Rep 2020;69(17):521–522. Crossref, Medline, Google Scholar , Google Scholar
• 7Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384(9953):1529–40. Crossref, Medline, Google Scholar , Google Scholar
• 8New York City Department of Homeless Services. Daily Report [Internet]. New York (NY): The Department; [cited 2020 Jun 2]. Available from: https://www1.nyc.gov/assets/dhs/downloads/pdf/dailyreport.pdf Google Scholar Google Scholar
• 9Theiss J, Schrag J, Teitelbaum J. A System-Level Approach to Addressing Health-Harming Legal and Social Needs: A Case Study of the NYC Health + Hospitals and LegalHealth Medical-Legal Partnership [Internet]. Washington (DC): National Center for Medical-Legal Partnership; [cited 2020 Jun 5]. Available from: https://medical-legalpartnership.org/wp-content/uploads/2019/04/A-System-Level-Approach.pdf Google Scholar Google Scholar