February 13, 2024 – Health related social needs

Audio recording here

Amanda McCarthy - Advanced Health - Health Related Social Needs - Director of Social Determinants of Health

• What’s covered:

  • Climate

    • Who is Eligible

      • Transition population

        • Homeless or at risk of homelessness

        • Dischargeed from adult BH residential

        • Child-welfaire involved

        • Trasitioning to dual status

        • Released from Incarceration

        • Youth with Special Health Care Needs (YSHCN)

        • Clinical or social risk factors

  • Housing

  • Cover temporary rental assistance for up to 6 months

    • Utility assisatance for up to 6 months

    • Pre-tenancy and tenancy support services

    • Housing -focused navigation and /or case management

  • Food

    • Who is Eligible

      • Members with an identified food insecurity need

      • Members with clinical risk factors where medically

• Who is Eligible

• Transition population

  • Homeless or at risk of homelessness

  • Dischargeed from adult BH residential

  • Child-welfaire involved

  • Trasitioning to dual status

  • Released from Incarceration

  • Youth with Special Health Care Needs (YSHCN)

  • Clinical or social risk factors

• Implementation timeline:

  • Climate Benefits - March 1, 2024 Population - Transitions

    Housing - November 2024 Population - At risk for homelessness as defined by HUD

  • Food - Januray 2025 Population: Members experiencing food insecurity & Members with a clinical need

• Refferals

  • Referral from CBO, ICC, healthcare providers and clinic care management teams

  • Member direct outreach by CCO

  • Existing Flex Fund or HRS requests (built in process to determine the best source of funding for the request)

  • UnitieUS Community Information Exchange

    • Primary referral pathway to the CCO for HRSN benfits

    • Screening and referral form in Unite Us will offer supporting details to determine HRSN eligibilty

    • Meets the closed loop referral requirement of the the benefit

• Care Management Requirements

  • Contract language: Person-Centered Service Plan (PCSP)

    • In writing and developed with an agreed upon by the member

    • At least one meeting required

    • 6 month check in after services rendered

    • PCSP must include:

      • The recommendded HRSN services

      • Service duration

      • Service provider

      • Goals of the HRSN service

      • The follow-up and transition plan

    • Care Plans may be required for all members receiving HRSN benefits

    • Care management can be done by the CCO,CBO or Primary care clinic

• Introductions of new members:

  • William Wagner LPC Roseburg VA work with suicide prevention

    • Saturday event

    • Advocate for the support systems supporting veterans

Community partner updateFlyers:

South Coast Together Brag Sheet

Friends of Bandon Parks Tri Fold

Devereux Center Needs

Devereux Center Brochure

Coos Hispanic Allies Agile Funds Flyer

Next month meeting - February 13, 2024 - Jamar Ruff - SCEC

March meeting - March 12, 2024 - Pamela Huntley - Systems of Care

Send suggestions for future topics to Jen Shafer director@unitedwayswo.org