Social Determinants of Health Data Drives Neighborhood Health Plan of Rhode Island to Add Companion Services to its Medicare-Medicaid Plan

Papa Pals is one of four additional benefits – provided at no extra cost – to supplement Neighborhood’s 2022 INTEGRITY Medicare-Medicaid Plan to improve the health of its most medically fragile and economically disadvantaged members

October 6, 2021 (Smithfield, RI) – With a long history of serving Rhode Island’s at-risk populations, Neighborhood Health Plan of Rhode Island (Neighborhood) relies on social determinants of health data to inform and action initiatives to improve the health of its members. That’s why Neighborhood is adding Papa Pals – a health resource for companion and assistance services – to its 2022 health plan benefit offerings for members of its INTEGRITY Medicare-Medicaid Plan. The new benefit for its dually-eligible members – some of Rhode Island’s most medically fragile and economically disadvantaged individuals – is designed to combat social isolation, loneliness and other social barriers. Neighborhood added the benefit after working closely with applied data science partner Algorex Health and identifying that its INTEGRITY members are 2.34 times more likely to be at high risk for social isolation than other adult members in the organization’s Medicaid and commercial plans.

“These findings are precisely why we continuously evaluate social determinants of health data across our member populations,” said Dr. Christopher Ottiano, medical director of Neighborhood. “Using this kind of data gives us the clinical insights we need to determine appropriate interventions that will improve health outcomes. In this case, we know a group of our members has a high incidence of social isolation, and that studies show social isolation is associated with about a 50% increased risk of dementia and other serious medical conditions. Offering Papa Pals services to our INTEGRITY members is one way we can make a difference.”

Papa Pals is one of four additional benefits that will supplement Neighborhood’s INTEGRITY plan in the coming year. Other benefits – all at no additional cost to members – include home-delivered meals from Mom’s Meals after a hospital stay or surgery; a Healthy Food Savings Card that provides members with a monthly allowance to spend on healthy foods; and a wellness benefit including a gym membership at six of the YMCA of Greater Providence branches. Approximately, 13,000 Rhode Islanders are covered by the INTEGRITY health plan and can use the new benefits starting on January 1, 2022.

Through Neighborhood’s partnership with Papa Pals, INTEGRITY members will have access to visits from a qualified, trained companion up to 120 hours per year. Multilingual “Pals” can help members with household chores, meal preparation, transportation, exercise and movement, electronic device guidance, and social activities at home, such as conversation, board games, reading and more.

Through Neighborhood’s partnership with Mom’s Meals, INTEGRITY members will receive, medically tailored, refrigerated prepared meals that are ready to heat and consume. Members can use this benefit following hospitalization or surgery. Before discharge, members are evaluated for food insecurities; meals from Mom’s Meals are then scheduled and delivered to the member’s door.

The free gym membership is offered in partnership with the YMCA of Greater Providence branches. This wellness benefit takes into consideration the language and transportation barriers facing many INTEGRITY members. The membership includes access to a bilingual YMCA liaison, transportation to and from the designated YMCA locations, and both in-person and virtual class offerings. An activity tracker is included with each gym membership

“Access to fitness activities, healthy food and social stimulation is integral to improving overall health,” said Dr. Ottiano. “Neighborhood is excited to continue finding ways, like these supplemental benefits, to reduce barriers our members face to improve their health and wellbeing. INTEGRITY members in particular are among our most medically fragile members as they are typically older individuals or adults with disabilities who have a wide range of health care needs and are often economically disadvantaged. As such, we place great emphasis on finding innovative ways to address their health care needs.”

All four new benefits will be available to INTEGRITY members in 2022 and will supplement the wide range of benefits currently covered by the health plan. Through Neighborhood’s current INTEGRITY Medicare-Medicaid Plan, members receive 24/7 care management, access to housing and rehabilitation specialists, long-term services and supports (LTSS), and other flexible benefits. Key benefits of the current plan include coordinated care teams, a person-centered approach to care; and one health insurance card that covers both Medicare and Medicaid services. Additionally, members have access to a care manager to help navigate the complexity of the system as well as maintain good health.

Neighborhood is the only health insurer in Rhode Island offering an integrated Medicare-Medicaid health plan with no plan premium or copays. For more information, call Neighborhood Member Services at 1-844-812-6896 (TTY711).

Neighborhood Health Plan of Rhode Island (Neighborhood) is a not-for-profit health maintenance organization (HMO) founded in December 1993 in partnership with Rhode Island’s Community Health Centers to ensure everyone in the state has access to high quality, cost-effective health care. Neighborhood serves nearly 217,000 members in the state with 81 percent of its membership Medicaid eligible through its ACCESS and TRUST plans and 6 percent of its membership utilizing Neighborhood’s INTEGRITY Medicare-Medicaid Plan (MMP). About 13 percent of Neighborhood’s members are individuals, families and small businesses who select one of eight Neighborhood commercial plans available through the health exchange, HealthSource RI. Of these members, about 85 percent qualify for federal subsidies to cover a portion of their costs. Today, Neighborhood—with over 600 employees and $1.4 billion in revenue—serves one out of every five Rhode Islanders. Learn more at