Integrated Care and Services to Address Social Determinants of Health

Our primary initiative is focused on service integration for the most vulnerable populations lacking access to quality health care and support services. The traditional fee-for-service model of healthcare delivery has relied on the assumption that all recipients of healthcare have an equitable opportunity to maintain their health. We hold the belief that health is influenced by unequal social and physical environments, long before an individual enters a doctor’s office. Integration of care promotes improved access to services and improved value in healthcare delivery.

As the result of an analysis of the local healthcare landscape, as well as dialogue with key stakeholders, we identified two distinct constituencies that we will focus our efforts on within this initiative:


The health of immigrant communities is an important component to the viability of Philadelphia. Approximately 13% of Philadelphia residents are foreign-born. A larger percentage of foreign-born residents are at the bottom of the earnings spectrum compared to native born residents, and about 1 out of 4 of Philadelphia’s foreign-born residents qualifies as low-income. Many new or non-citizen immigrants do not qualify for Medicaid, including children who do not qualify for CHIP. Many of these individuals struggle with below average access to healthcare and gainful employment, and low literacy rates. Existing obstacles that impact their quality of life include language barriers, lack of cultural competency among providers, restricted access to public benefits, and stigma. By directing resources to efforts that minimize these barriers, these individuals will have a more equitable opportunity to access and successfully utilize resources that exist in Philadelphia.

Health and social services are limited and lack of government funding, especially for undocumented immigrants, leaves service organizations dependent upon scant private support. With limited capacity, it is important to invest in services that are well-coordinated to maximize efficiency and aim to increase an individual’s autonomy so that dependency on support services decreases over time. To address common barriers that immigrants and refugees face to accessing care, we will focus on outreach and engagement to promote health literacy, and workforce development to prepare individuals for health-related careers.


We have supported a variety of services to children, including vision, dental, child advocacy, violence prevention, maternal, prenatal, and nutrition. The health and well-being of children is paramount to the future of Philadelphia and this country, yet still over one-third of Philadelphia children live in families below the poverty line. Children living below the poverty lines are less likely to access a regular source care compared to their counterparts. Focusing on the social determinants of health with a multi generation approach that improves the environment for children to thrive continues our commitment to wellbeing. Supporting targeted community-based services to parents and caregivers including supportive housing, legal services (Medical Legal Partnerships), parenting education, and trauma-informed services would bring us closer to the goal of prosperous children.

Through this initiative, we will support evidence-based models and innovative approaches to coordinating services for children and their families, as well as community-based strategies to strengthen families.