Screener ELearning Course 1 - Social Care Network 101

Lessons 1-5

Social Care Network (SCN)

A grant program under the 1115 Waiver connecting organizations to address health-related social needs for Medicaid members in New York State.

Health-Related Social Needs (HRSN)

Social and economic needs impacting health and well-being, such as food, housing, and transportation.

Social Determinants of Health (SDOH)

Conditions in which people are born, grow, live, work, and age that affect health outcomes. Health Related Social Needs fall within this framework.

Community-Based Organization (CBO)

Local organizations providing services to meet needs like food and housing. These are organizations are key partners in the Social Care Network.

Managed Care Organization (MCO)

• Health care companies providing covered services through a provider network. • They coordinate care for Medicaid members.

Medicaid Managed Care (MMC)

A program where Medicaid pays managed care plans to provide benefits to enrollees through a provider network.

Medicaid Fee-For-Service (FFS)

A payment model where Medicaid pays doctors directly for services provided to members, instead of through managed care.

Accountable Health Communities Health Related Social Needs Screening Tool (AHC HRSN Screening Tool)

The standard New York State assessment tool used to identify unmet health-related social needs (HRSNs).

Social Care Network Lead Entity Core Functions

1. Coordination of Service Delivery

2. Network Governance & Operations

3. Data Sharing Facilitation

4. Capacity Building

5. Contracting & Fiscal Management

Coordination of Service Delivery

• PHS ensures that HRSN services are delivered to Medicaid members in a manner that is efficient, equitable, and timely.

• This involves coordinating various service providers and streamlining processes to minimize delays and disparities in service delivery.

• By focusing on equitable access, PHS helps ensure that all members receive the support they need, regardless of their circumstances or location.

Network Governance & Operations

• PHS is responsible for developing, managing, and overseeing the network’s structure, policies, and daily operations.

• This includes establishing clear guidelines and protocols to ensure the network functions smoothly and effectively.

• Through robust governance, PHS maintains accountability and fosters collaboration among network partners to achieve shared goals.

Data Sharing Facilitation

• PHS enables secure and efficient data exchange across the network to support navigation and service delivery.

• This ensures that critical information is accessible to the right stakeholders at the right time.

• By prioritizing data security and accuracy, PHS enhances the ability of providers to coordinate care and improve outcomes for Medicaid members.

Capacity Building

• PHS invests in training programs and resources to help organizations meet the growing demand for HRSN services.

• These efforts aim to strengthen the capabilities of network partners and improve service quality.

• By building capacity, PHS ensures that organizations are well-equipped to address the complex needs of Medicaid members effectively and sustainably.

Contracting and Fiscal Management

• PHS manages contracts and financial flows between network partners and payers to ensure transparency and efficiency.

• This includes overseeing budgets, payments, and compliance with financial agreements.

• Through effective fiscal management, PHS supports the financial stability of the network and fosters trust among all stakeholders.

SCN Lead Entity

PHS coordinates the network of HRSN service providers and healthcare providers, manages contracts, oversees performance, and ensures effective operations and data sharing.

Community-Based Organizations (CBOs)

Nonprofit organizations that provide HRSN services, conduct screenings, assist members in navigating services, and deliver community-tailored support.

Healthcare Providers

Screen members for social needs, connect them to appropriate services, and bridge health and social care through behavioral and primary care practices.

Managed Care Organizations (MCOs)

Provide secure Medicaid member information, identify eligibility for HRSN services, and manage payment flows to the SCN.

Ecosystem Partners

Collaborate with the network to extend its reach and impact, including local agencies, departments, and other healthcare providers.

Step 1 of the Collaboration Process: Member Identified with a Need

• A member is recognized as having a health-related social need.

• This identification can occur through a healthcare provider, community-based organization (CBO), or managed care organization (MCO).

Step 2 of the Collaboration Process: Screening and Eligibility Assessment

• The member is screened using the Accountable Health Communities Health-Related Social Needs (AHC HRSN) tool.

• Based on the results, their eligibility for enhanced services is determined.

Step 3 of the Collaboration Process: Referral Sent via Unite Us

A referral is created and sent through the Unite Us platform to connect the member with the appropriate service provider.

Step 4 of the Collaboration Process: Service Provision and Case Updates

• The designated service provider delivers the necessary support to the member and updates the member’s case in Unite Us.

• This ensures that all stakeholders remain informed about the member’s progress.

Step 5 of the Collaboration Process: Closed-Loop Referral and Outcome Sharing

• Once the required services have been delivered, the referral is closed.

• Outcomes are then shared across the network, allowing all parties to track the member’s progress and the overall impact of the intervention.

Member-Facing Staff (Screeners, Navigators, Service Providers)

• Member-facing staff are the frontline workers who interact directly with Medicaid members.

• They conduct screenings, provide navigation support, and deliver enhanced HRSN services as needed.

• These staff members are responsible for ensuring that members’ needs are identified and addressed promptly.

• Their work is essential for connecting members to the right resources and tracking progress in the Unite Us platform.

Supervisors and Referral Admins

• Supervisors oversee the work of member-facing staff, ensuring quality and compliance with network standards.

• Referral Admins manage the flow of referrals within the organization, assigning cases and monitoring outcomes.

• Both roles are crucial for maintaining smooth operations and supporting staff in delivering effective care.

• They help resolve issues, provide guidance, and ensure that all referrals are handled efficiently.

Administrators (Org Admin, Invoice Admin)

• Administrators manage organizational settings, user permissions, and invoicing processes in Unite Us.

• Org Admins oversee the overall functioning of the organization within the platform.

• Invoice Admins review and approve invoices before they are sent to the SCN Lead Entity, ensuring accuracy and compliance with reimbursement requirements.

Intake Coordinator

• The Intake Coordinator reviews all incoming referrals and assigns them to the appropriate staff members.

• This role is key to making sure that no referral is missed or delayed.

• By managing the intake process, this user persona helps maintain a steady workflow and ensures that members receive timely support.

Enhanced Social Care Navigator

• Enhanced Social Care Navigators have advanced permissions in Unite Us.

• They can complete screenings, conduct eligibility assessments, provide navigation support, and update social care plans.

• This role is central to coordinating care for members with complex needs, ensuring that all aspects of their journey are tracked and managed effectively.

Service Provider

• Service Providers deliver direct enhanced services to members and document these services in Unite Us.

• They are responsible for closing cases after service delivery and generating invoices for reimbursement.

• This user persona ensures that services are properly recorded and that the organization receives payment for contracted activities.

Health-Related Social Needs (HRSNs)

• Health-Related Social Needs (HRSNs) are individual-level factors that impact a person's health, such as access to housing, food, transportation, and employment.

• These differ from Social Drivers of Health (SDOH), which are broader, community-level factors like neighborhood safety or local economic conditions.

• When HRSNs go unmet, they can lead to gaps in healthcare, increased costs, and poorer health outcomes.

• Understanding both HRSNs and SDOH helps organizations address health issues more effectively at both the individual and community levels.

Social Drivers of Health (SDOH)

• The conditions in which people are born, grow, live, work, and age.

• These factors significantly influence health outcomes and contribute to disparities across populations.

AHC HRSN Screening Tool

• A standardized questionnaire used to identify health-related social needs in Medicaid members.

• It covers areas like housing, food, transportation, employment, education, and interpersonal safety.

• This tool ensures consistency and thoroughness in identifying needs.

Who can conduct screenings?

• Screenings may be conducted by HRSN service providers, SCN Navigators, Health Homes, Federally Qualified Health Centers (FQHCs), healthcare providers, behavioral health providers, and hospitals.

• Members can also self-screen through the SCN website, but reimbursement requires follow-up by a staff member.

Where do screenings take place?

• Screenings can occur in a variety of settings, including healthcare facilities, community-based organizations, hospitals, and online via the SCN website.

• The flexibility ensures members can be reached wherever they are most comfortable.

When are members screened (annual & major life events)?

• Every Medicaid member is screened at least once a year.

• Additional screenings are conducted if a member experiences a major life event, such as a change in housing, income, or family structure, to ensure their needs are reassessed promptly.

What are examples of major life events?

• Major life events include changes in functioning or health, hospital admissions or discharges, serious injuries, significant changes in housing or income, family changes like marriage or childbirth, arrests, or changes in benefits.

• These events may trigger a re-screening to address new or evolving needs.

HRSN Screening

Systematic process used to identify Medicaid members who may have unmet social needs, such as housing, food, or transportation.

Step 1 of HRSN Screening: Member Identified for Screening

A Medicaid member is identified as needing a screening, either as part of their annual check or due to a major life event.

Step 2 of HRSN Screening: Screening Conducted Using AHC Tool

The screener uses the standardized AHC HRSN tool to assess the member’s needs in areas like housing, food, and transportation.

Step 3 of HRSN Screening: Results Documented in Unite Us

All screening results, including time spent and any unanswered questions, are entered into the Unite Us platform for tracking and compliance.

Step 4 of HRSN Screening: Referral for Assessment or Navigation

• If unmet needs are found, the member is referred for an eligibility assessment or navigation to appropriate services.

• If no needs are identified, the member is thanked and informed about the next screening schedule.

Consent and Attestation: Eligibility Assessment Key Component

• Before starting the assessment, providers must obtain the member’s consent to proceed and a verbal attestation that the information provided is complete and accurate.

• This ensures the process is transparent and respects the member’s rights.

• Documenting consent and attestation is required in the Unite Us platform.

• This step protects both the member and the organization by confirming agreement and accuracy.

Demographic & Clinical Criteria: Eligibility Assessment Key Component

• Providers collect demographic information, such as age, disability status, and other relevant details, along with clinical criteria like chronic conditions or recent hospitalizations.

• These factors help determine eligibility for enhanced services.

• Accurate demographic and clinical data ensure that members are matched with the most appropriate services and that eligibility decisions are based on up-to-date information.

Social Risk Factors

• The assessment includes questions about social risk factors, such as housing instability, food insecurity, or lack of transportation.

• Identifying these risks is crucial for tailoring support to each member’s unique situation.

• Understanding social risk factors helps providers prioritize services and address the root causes of health challenges, leading to better outcomes.

Existing Services Inquiry

• Providers ask about any services the member is already receiving, such as SNAP, WIC, or other support programs.

• This prevents duplication and ensures coordination of care.

• Knowing what services are already in place allows providers to fill gaps and avoid unnecessary referrals, making the process more efficient for both members and staff.

Confirming Member’s Desire for Services

• Finally, providers confirm that the member wants to receive additional services.

• This step centers the member’s preferences and ensures that support is only provided when desired.

• Respecting member choice is fundamental to person-centered care and helps build trust between members and providers.

Navigation Workflow

Designed to ensure that members with identified needs receive personalized, coordinated support from assignment to outcome tracking.

Step 1 of Navigation Workflow: Member Assigned to Navigator

The member is assigned to a Social Care Navigator who will guide them through the process and serve as their main point of contact.

Step 2 of the Navigation Workflow: Social Care Plan Created

The Navigator creates a Social Care Plan in Unite Us, documenting the member’s needs, preferences, and any special considerations.

Step 3 of the Navigation Workflow: Document Needs and Barriers

The Navigator records specific needs, barriers to care, and the member’s preferences, ensuring culturally responsive and individualized support.

Step 4 of the Navigation Workflow: Referrals and Coordination

• Referrals are made to enhanced HRSN services or other appropriate programs.

• The Navigator coordinates with providers to ensure timely service delivery.

Step 5 of the Navigation Workflow: Track Progress & Update Plan

The Navigator tracks the member’s progress, updates the Social Care Plan as needed, and manages closed-loop referrals to confirm that services are received and outcomes are achieved.

Navigation Best Practices - Member Does NOT Respond

• If a member does not respond to outreach for eligibility assessment, outreach is not reimbursable.

• Document all attempts in Unite Us.

Navigation Best Practices - Updating the Social Care Plan

Regularly update the Social Care Plan to reflect changes in needs, preferences, and progress toward goals.

Navigation Best Practices: Closed-Loop Referral

A closed-loop referral means the Navigator tracks the referral from initiation to service delivery, ensuring accountability and follow-up.

HRSN Screening: Criteria and Compliance

• Screening must be conducted by an employee of an organization contracted within the Network.

• Member consent for data sharing is required. Screenings must use the NYS AHC HRSN Screening Tool and be performed for Medicaid members (FFS or MMC).

• All screenings must be entered into Unite Us, including the time spent.

• Only 1:1 interactions are reimbursable, and the screening must be the member’s annual screen or a verified re-screen due to a major life event.

Social Care Navigation: Steps and Documentation

• Navigation must be provided for enrolled Medicaid members whose HRSN screens show unmet needs and who want support.

• Only Social Care Navigators can perform navigation, and it must be documented in Unite Us.

• Automated programs or websites are not reimbursable.

• Outreach alone, without member engagement, is not reimbursed.

Enhanced HRSN Service Delivery: Types and Pathways

• Services must be delivered by employees of contracted organizations and referred through the SCN pathway by a Social Care Navigator using Unite Us.

• The member must meet enhanced HRSN eligibility, and the services provided must be among those approved by the SCN program.

• Key domains include nutrition, housing, social care management, and transportation. Some services, like nutrition, have special eligibility rules.

Member Self-Screening

Self-screening without a 1:1 interaction with a screener or navigator is not reimbursable.

Documentation for Navigation

Navigation must be documented in Unite Us and performed by a Social Care Navigator to be reimbursed.

Automated Navigation

Navigation conducted through automated programs or websites is not eligible for reimbursement.

Nutrition Services

Managed Long Term Care Plan and Medicare Advantage Plus members are not eligible for nutrition services reimbursement.

Eligible Member Types

• Eligible members include those enrolled in Medicaid Managed Care (MMC) or Fee-for-Service (FFS) who meet enhanced population criteria.

• Enhanced populations include high utilizers, Health Home members, individuals with substance use disorder or serious mental illness, intellectual or developmental disabilities, pregnant/postpartum persons, those recently released from incarceration, and high-risk children.

Excluded Populations

Certain groups are not eligible for screening or navigation, such as those with provisional Medicaid, emergency services only, Medicare Savings Program, Family Planning Benefit Programs, residents of state psychiatric facilities, currently incarcerated individuals, and others as defined by specific codes.

Frequency Rules

• Each Medicaid member is eligible for one reimbursed HRSN screening annually.

• Additional screenings are allowed if triggered by a major life event, such as a significant change in health, housing, income, or family status. Navigation and service delivery must also follow program-defined timelines and requirements.

Special Cases: Nutrition Services

• Managed Long Term Care Plan (MLTCP) and Medicare Advantage Plus (MAP) members are not eligible for nutrition services reimbursement, as these are covered by their plan benefits.

• However, they may be eligible for other enhanced HRSN services.

Step 1 of Ensuring a Reimbursable Activity: Confirm Member Eligibility and Consent

Before beginning any activity, verify that the member meets eligibility criteria and obtain their consent for participation and data sharing.

Step 2 of Ensuring a Reimbursable Activity: Complete the Required Activity

Perform the screening, navigation, or service delivery according to SCN guidelines, ensuring all steps are followed and the member is engaged.

Step 3 of Ensuring a Reimbursable Activity: Document in Unite Us

• Enter all required data fields in Unite Us, including time spent, member consent, and outcomes.

• Ensure accuracy and completeness for compliance.

Step 4 of Ensuring a Reimbursable Activity: Submit for Review/Approval

Depending on your user role, submit the documented activity for review and approval by the appropriate team member (e.g., Invoice Admin).

Step 5 of Ensuring a Reimbursable Activity: Address Errors or Missing Information

• If any errors or missing information are identified, correct them promptly to avoid delays in reimbursement.

• Regularly review submissions for compliance.

Screener

• Screening Users can complete the NYS AHC Screening Tool for members and enter results into Unite Us.

• Their actions automatically generate an invoice for reimbursement, provided all compliance requirements are met.

• They are responsible for ensuring screenings are conducted 1:1, member consent is obtained, and all data is entered accurately.

• Only Level 1 screenings are permitted for this user role.

Enhanced Social Care Navigator

• Enhanced Social Care Navigators can conduct screenings, eligibility assessments, and provide navigation support (Level 1 or 2).

• They can also request or add enrollment in enhanced HRSN services and update social care plans as needed.

• This role requires thorough documentation in Unite Us, including all navigation activities and member interactions.

• Navigators play a key part in ensuring compliance for navigation reimbursement.

Intake Coordinator

• Intake Coordinators review and act on incoming referrals in Unite Us, assigning them to internal staff as needed.

• They help ensure that referrals are processed efficiently and routed to the correct team members.

• While not directly responsible for billing, their timely actions support the workflow that leads to successful reimbursement for services provided.

Invoice Admin

• Invoice Admins review and approve all invoices generated by their organization before submission to the SCN Lead Entity.

• They are responsible for ensuring accuracy and compliance in all billing documentation.

• This role is critical for catching errors or omissions before invoices are submitted, helping to prevent delays or denials in reimbursement.

Service Provider

• Service Providers deliver enhanced HRSN services directly to members and document these activities in Unite Us.

• Their documentation generates invoices for reimbursement and is essential for closing cases after service delivery.

• They must ensure that all services provided are among those approved by the SCN program and that all required information is entered for payment to be processed.

Step 1 of Invoicing Process: Service Activity Completed

• After providing and documenting an eligible service in Unite Us, the invoicing process begins.

• Ensure all service details are accurate and complete before moving forward.

Step 2 of Invoicing Process: Invoice Generated

• For each eligible activity, an invoice is either auto-generated by the system or manually created.

• Double-check that all necessary information is included to avoid delays.

Step 3 of Invoicing Process: Invoice Reviewed by Admin

• The Invoice Admin reviews the invoice for accuracy, completeness, and compliance with SCN requirements.

• Any errors or missing information should be addressed before submission.

Step 4 of Invoicing Process: Invoice Submitted to PHS

• Once approved internally, the invoice is submitted to Public Health Solutions (PHS) through Unite Us.

• Timely submission—ideally every week—ensures prompt processing.

Step 5 of Invoicing Process: Invoice Approved & Paid

• PHS reviews the submitted invoice, approves it if all requirements are met, and processes payment.

• If issues are found, the invoice may be returned for correction and resubmission.

Troubleshooting Common Invoicing Scenarios: Submitting an Invoice for a Completed Service

• After completing and documenting a service, review all required fields in Unite Us before submitting the invoice.

• Double-check for accuracy to prevent delays in approval.

• If everything is correct, submit the invoice for internal review by the Invoice Admin.

• Timely submission helps ensure your organization receives payment promptly.

Troubleshooting Common Invoicing Scenarios: Correcting an Error Before Approval

• If you notice an error in an invoice before it is approved, update the information directly in Unite Us.

• Common errors include missing service details or incorrect dates.

• Communicate with your Invoice Admin to confirm the correction has been made.

• Addressing errors early prevents rejections and speeds up the approval process.

Troubleshooting Common Invoicing Scenarios: Addressing Missing Documentation

• If documentation is incomplete, gather and upload the necessary information as soon as possible.

• Missing documents can delay or prevent reimbursement.

• Notify the Invoice Admin once the documentation is complete so the invoice can move forward in the approval process.

Troubleshooting Common Invoicing Scenarios: Responding to a Rejected Invoice

• If an invoice is rejected by PHS, review the feedback provided in Unite Us to understand what needs to be corrected.

• Common reasons for rejection include incomplete information or non-compliance with SCN requirements.

• Make the necessary corrections and resubmit the invoice promptly. Learning from feedback helps prevent similar issues in the future.

Best Practices & Common Pitfalls: Submit Invoices Weekly

Submitting invoices every week ensures timely reimbursement and keeps your organization in compliance with SCN requirements.

Best Practices & Common Pitfalls: Check Documentation Thoroughly

Always review all documentation before submitting an invoice to prevent delays or rejections due to missing information.

Best Practices & Common Pitfalls: Correct Errors Promptly

If you find an error, correct it immediately and communicate with your Invoice Admin to keep the process moving smoothly.

Best Practices & Common Pitfalls: Respond Quickly to Feedback

When an invoice is returned or rejected, address the feedback and resubmit as soon as possible to avoid payment delays.

Best Practices & Pitfalls: Coordinate with Your Team

Regular communication with your team helps catch issues early and ensures everyone follows best practices for invoicing.