For healthcare providers, Medicare beneficiaries pose challenges including multiple chronic conditions. Serving Medicaid beneficiaries can be equally challenging, with relatively low reimbursement rates.

One of the most important factors that has led to SOMOS’s success in serving Medicare and Medicaid patients is the way that the physician network has built a Social Care Network model to serve 1 million Medicaid and Medicare patients in predominantly Latino and Asian American communities across New York City, says Chief Medical Officer Yomaris Peña, MD.

“When patients visit one of SOMOS’ 2,500 providers, we don’t just address their conditions or health at face value,” she says. “SOMOS providers pay special attention to social determinants of health, including housing conditions, nutrition, socio-economic status, language barriers, and immigration status, and we connect them to resources to help them mitigate the effects of these factors on their health.”

When SOMOS providers work with their patients, they fundamentally understand patient concerns, Peña says.

“When a patient needs to change their diet, SOMOS providers help the patient alter their nutrition without losing their traditional foods,” she says. “When a patient needs exercise, providers tell them about the free pool in their neighborhood. When a patient is hesitant to talk about their mental health, providers screen at every appointment and come to them from a place of understanding to help them work through culturally prominent stigmas. We have family offices, embedded in the neighborhoods and communities that they serve, with open-door policies and welcoming atmospheres.”

SOMOS has a Social Care Network with a focus on addressing health inequities as well as providing solutions for a broad array of social care needs for those who are chronically sick, hardest to reach, and persistently overlooked, Peña says.

“To break down these systemic inequities and fully address whole-person health needs with a preventative focus, SOMOS engages in community-based public health engagement and education with a trusted workforce that is part of the fabric of the community,” she says. “SOMOS establishes partnerships with community-based organizations for the provision of comprehensive social assistance for community members including housing and food assistance.”

SOMOS has embraced value-based care to rise to the financial challenges of serving Medicare and Medicaid beneficiaries. SOMOS was founded in 2014 as the only physician-led Performing Provider System in New York State’s Delivery System Reform Incentive Payment (DSRIP) program. Advanced value-based care models mean building stronger preventative care services, mental health screenings, and addressing issues such as nutrition and housing so patients have better long-term outcomes, Peña says.

“SOMOS has demonstrated that advanced value-based care models intertwined with culturally competent healthcare is the most efficient way to improve patient outcomes for the Medicaid population, all while saving New York State tax revenue over the course of the five-year DSRIP timeframe,” she says. “We have also successfully implemented our accountable care organization model for a decade, ensuring our Medicare population is taken care of and not overlooked.”

Culturally competent care is a cornerstone of the SOMOS model of care, Peña says.

“SOMOS’s approach to connecting with patients in their own language and shared cultural context has been proven to decrease healthcare costs and to reach New York’s goal of reducing hospital admissions and readmissions,” she says. “When our patients walk into the waiting room and the exam room, they feel understood, welcomed, and like they can fully express their concerns in the way they are most comfortable. Culturally competent care can be as simple as a doctor advising patients on their carbohydrate intake, for instance, recommending a Dominican patient to limit their plantain intake or suggesting a Mexican patient to reduce their tortilla intake. At its core, it’s about truly understanding the patient and meeting them where they are, in a way that builds trust.”