Somos Community Care

In 2023, SOMOS continued to build the capacity of network providers to engage in value-based care initiatives including practice transformation and capacity building; secure bidirectional exchanges and critical connectivity; engage in strategic communications and community education; as well as continuing COVID-19 pandemic response efforts. The organization is engaged in supporting a growing network of Health Related Social Needs (HRSN) providers in an innovative Social Care Network 1115 waiver funded program in New York State. The organization engaged in sustainable, critical practice transformation and capacity-building activities including expanding Patient-Centered Medical Homes (PCMH), assisting in closing care gaps, care management, care coordination, and deploying Community Health Workers (CHWs). The organization secured bidirectional exchanges and ensured critical connectivity, centralized Information Technology (IT) system, and enhanced the Electronic Health Record (EHR) systems. SOMOS also facilitated data warehouse and data analytics for providers to improve the quality of care and identify gaps in care. SOMOS has facilitated the growth of a diverse network of providers dedicated to whole-person integrated care and addressing health inequities amongst underserved residents of New York City. SOMOS reached, meaningfully engaged, and sustained the active participation of patients in their health, by engaging in advertising, marketing, communications, education, events, digital marketing, patient-use tools, health fairs and events, research and data, and strategic partnerships.