Montefiore St. Luke's Cornwall, Access, and Independent Living Put Social Care Navigators in the ER
NEWBURGH, N.Y. (August 3, 2026) — Montefiore St. Luke's Cornwall (MSLC), in partnership with Access: Supports for Living and Independent Living, has launched an innovative Emergency Department-based Social Care Navigation program designed to connect eligible Medicaid patients with community resources that support their overall health and well-being.
While every patient comes to the Emergency Department for medical care, some also face non-medical challenges that can affect their recovery, such as transportation barriers, food insecurity, housing instability, or difficulty accessing community services. By identifying these needs during an ED visit, the program helps ensure patients leave the hospital with connections to resources that support their continued health.
Research consistently demonstrates that health is influenced not only by the care patients receive in hospitals and physician offices, but also by factors such as stable housing, access to nutritious food, reliable transportation, and community support. Recognizing these connections, MSLC partnered with Access: Supports for Living and Independent Living to bring social care resources directly into the Emergency Department for eligible patients who may benefit from additional support after discharge.
The program operates through New York State's Social Care Network (SCN), a Medicaid-funded initiative administered locally by the Hudson Valley Care Coalition (HVCC), which coordinates social care services through community-based organizations across seven Hudson Valley counties.
Expanding Care Beyond the Bedside
Each morning, a behavioral health clinician at MSLC identifies every Medicaid patient currently in the emergency department who may be eligible for the Social Care Network Program. That list goes to community navigators from Access and Independent Living credentialed authorized under a formal Memorandum of Agreement (MOU) who approach patients directly, conduct social needs screenings on the spot, and connect those who qualify to food, housing support, transportation, and peer services.
“Our Emergency Department cares for hundreds of patients every day, each with unique medical and personal circumstances," said Patricia Tuber, Assistant Vice President of Behavioral Healthcare at MSLC. "During the course of an emergency visit, there are opportunities to identify patients who may benefit from additional community support. By connecting eligible patients with experienced navigators while they are already receiving care, we can strengthen their transition home and improve access to resources that support their long-term health."
"The goal from the beginning has been collaboration, not duplication," said Marlene Ripa, Senior Vice President of Business Development and Network Strategy at MSLC and a member of the HVCC Board of Directors. "This program is the natural evolution of Orange County's history of cross-sector partnership, bringing community resources into the hospital so we can reach people at the right moment."
Access navigators hold dual roles as social care screeners and health home care managers, allowing them to address immediate needs and longer-term care coordination in a single encounter. Independent Living brings peer navigation, individuals with lived experience who build trust with patients reluctant to engage with traditional providers.
"Connecting with patients while they are still in the Emergency Department gives us the opportunity to establish trust, understand their needs, and begin coordinating services before they leave the hospital," said Lauren Owens, Care Management Director at Access: Supports for Living. "That early connection significantly increases the likelihood that patients will engage with the resources available to them."
"We've seen how meaningful it is to meet patients at a critical moment," said Nora Shepard, Director of Crisis Response and Community Programs at Independent Living, Inc. "When people are connected with someone who understands their experience and can guide them toward available resources, they're often more willing to accept help and continue engaging with services after they leave the hospital.
"Early Results
Since launching earlier this year, the program has completed hundreds of social needs screenings for eligible Medicaid members, with participation continuing to grow each month. The collaborative approach has also increased awareness among Emergency Department physicians, nurses, and clinical staff, who now routinely identify patients who may benefit from community-based services and make referrals to the navigation team.
A Model for the Hudson Valley
"What MSLC, Access, and Independent Living have built in Orange County is exactly the vision of the Social Care Network in action," said Meghan Weygant, Chief Operating Officer, Hudson Valley Care Coalition. "They identified a gap, brought the right partners to the table, and built something that is already changing lives. Our goal is to see this model replicated across all seven counties we serve. Since the launch of the Social Care Network, our partners have now completed more than 120,000 health-related social needs screenings across the Hudson Valley. Programs like this show what those screenings can become when they're paired with trusted community partners who can connect people to meaningful support."
HVCC is actively working with hospital systems, and community partners across the region to expand embedded navigator models to additional sites and counties.
"At Montefiore St. Luke's Cornwall, our mission is to care for the whole person," said Daniel J. Maughan RN, FNP-C, President and CEO of MSLC. "This partnership demonstrates what is possible when healthcare organizations and community agencies work together to improve access to care beyond the hospital walls. By connecting eligible patients with resources that support their health after discharge, we're strengthening outcomes while advancing our commitment to healthier communities."
About Montefiore St. Luke’s Cornwall
Montefiore St. Luke’s Cornwall (MSLC) is one of nine hospitals within the Montefiore Health System (MHS). MSLC is dedicated to serving the healthcare needs of the Hudson Valley. Through its system relationship with MHS, MSLC provides the necessary tertiary and quaternary care to best care for more than 200,000 patients annually. For more information, please visit www.montefioreslc.org.
About Access: Support Services
Access: Supports for Living is a nonprofit organization serving more than 20,000 people annually across the Hudson Valley, New York City, and Long Island. Founded in 1963 by local parents seeking better lives for their children with disabilities, Access today provides mental health, substance-use, intellectual and developmental disability services, housing, employment, children’s services, and community supports. Through its network of affiliates - The Guidance Center of Westchester, Meaningful NY, and New York Families for Autistic Children - Access continues to deliver its mission: to help people live the healthiest and fullest lives possible.
About Independent Living, Inc.
Independent Living, Inc., is a nonprofit agency operated by people with disabilities for people with disabilities. The organization strives to be the bridge that enables individuals, regardless of age or disability, to embrace their full potential and thrive in a fully integrated and barrier-free society.
About the Hudson Valley Care Coalition (HVCC)
The Hudson Valley Care Coalition (HVCC) is the lead entity for the Social Care Network (SCN) serving seven counties across the Hudson Valley: Orange, Ulster, Sullivan, Dutchess, Putnam, Rockland, and Westchester. As part of New York State's Medicaid 1115 Waiver, the SCN connects Medicaid members to services that address health-related social needs — including food and nutrition, housing support, and transportation — and coordinates across healthcare providers and community-based organizations to ensure members receive the support they need to stay healthy. To learn more, visit hudsonvalleycare.org and connect with us on social media: @hudsonvalleycarecoalition.
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Press Contact: Lisa Kaslyn, Harry Marketing, lisak@harry.marketing, 917-723-6298
