Social Care Networks (SCN)

Increasing and strengthening the delivery of social care services to Medicaid members across New York State.

Introduction

The mission of New York State is to protect and promote health for all, building on a foundation of health equity. In New York and nationally, there is growing recognition that fully achieving health for all requires a focus not only on physical and behavioral health but also on health-related social needs (HRSNs).

It is now widely acknowledged that addressing social needs such as food insecurity, housing instability, and lack of transportation improves health and lowers healthcare costs. To ensure that these needs are consistently addressed for New York’s Medicaid Members, New York needs a coordinated infrastructure and set of processes through which a member’s unmet social needs can be identified, members can be connected to services to address those needs, and the organizations who provide those services can be paid.

On January 9, 2024, the Centers for Medicare and Medicaid Services (CMS) approved the New York Health Equity Reform (NYHER) 1115 Waiver Demonstration Amendment, including new funding to establish Social Care Networks (SCNs) and deliver health-related social needs (HRSN) services.  

Pie of Ecosystem partners/social care network/Medicaid members

The establishment of Social Care Networks (SCNs) is a core part of the NYHER Amendment. The role of 9 regional SCN Lead Entities will be to contract and coordinate with a network of Community-Based Organizations (CBOs) and other organizations providing health-related social needs (HRSN) services, and to coordinate healthcare providers (inclusive of behavioral health and primary care providers).

Together, each Network will be responsible for ensuring that there is a seamless, consistent, end-to-end process in their region for HRSN Screening, Navigation, and delivery of HRSN services. This will require close collaboration within each Network, as well as shared data and technology provided by the State. Social Care Networks (SCNs) will also engage a broader ecosystem of partners to achieve their goals, including health insurance plans, local government, and child & family supports.


Social Care Networks will Achieve Four Goals for Medicaid Members:

  1. Expand access to high-quality HRSN services
  2. Enable consistent, timely screening using the Accountable Health Communities (AHC) HRSN Screening Tool and Navigation to HRSN services
  3. Create shared end-to-end visibility of the Member journey from HRSN Screening and Navigation through delivery of HRSN services
  4. Strengthen collaboration between HRSN service providers and other partners in their regional health ecosystem, including, providers, care managers, and health plans
Pie of Ecosystem partners/social care network/Medicaid members
Lead Entities Map Color Counties
Care Compass Collaborative Broome, Chenango, Delaware, Otsego, Tioga, Tompkins
Forward Leading IPA Allegany, Cayuga, Chemung, Genesee, Livingston,Monroe, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, Yates
Health and Welfare Council of Long Island Nassau, Suffolk
Healthy Alliance Foundation Inc.
1
 Albany, Columbia, Greene, Rensselaer, Montgomery, Saratoga, Schenectady, Schoharie
2
 Cortland, Herkimer, Madison, Oneida, Onondaga, Oswego
3
 Clinton, Essex, Franklin, Fulton, Hamilton, Jefferson, Lewis, St. Lawrence, Warren, Washington
Hudson Valley Care Coalition, Inc. Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester
Public Health Solutions Manhattan, Queens, Brooklyn
Staten Island Performing Provider System Richmond
Somos Healthcare Providers, Inc. Bronx
Western New York Integrated Care Collaborative Inc. Cattaraugus, Chautauqua, Erie, Niagara

For Social Care Networks (SCNs) to truly serve as an interconnected Network that identifies and addresses health-related social needs (HRSNs), many kinds of data and information need to be shared across organizations, and do so with standardized instruments and metrics. Further, data privacy and security are crucial for the SCN Lead Entity to protect sensitive Member information from being misused or accessed by unauthorized people. The below resources provide more information:

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