1115 Medicaid Waiver Screening and Navigation
Vita Valens has joined the New York State Social Care Network, supported by the Medicaid 1115 Waiver, to screen and connect individuals on Medicaid to social resources like food, transportation, housing, and other Health-Related Social Needs (HRSNs).
What is HRSNs Screening?
Health-Related Social Needs (HRSNs) screening is a structured, supportive conversation that helps us understand the full picture of a member’s life. It is not just their health, but the social, economic, and environmental factors that shape it. Using the federally developed Accountable Health Communities (AHC) tool, Vita Valens screens members across six key life domains to identify unmet needs and open the door to real support.
Areas we screen:
- Housing & Utilities
- Food Security
- Transportation
- Employment
- Education
- Interpersonal Safety
The Screening Process
Step 1: Introduction and Consent
Our team introduces themselves and explains the purpose of the screening. Members are informed that their responses are confidential and will not affect their Medicaid benefits. Consent is collected before any questions are asked, and members may pause or stop at any time.
Step 2: Member Verification
We verify Medicaid enrollment and confirm the member’s information in our system to ensure services are accurately coordinated.
Step 3: Administering the AHC Screening Tool
Using the Accountable Health Communities (AHC) tool, members are guided through questions across six areas: housing, food security, transportation, employment, education, and interpersonal safety. Each question is read aloud at a comfortable pace. For children under 10, a parent or caregiver may respond on their behalf.
Step 4: Documentation in Unite Us
Responses are securely documented to ensure each member’s needs are accurately on record and can be referenced for ongoing support.
Step 5: Navigation & Referral
When needs are identified, members are connected to community resources such as housing assistance, food programs, and transportation support.
If a member is not ready at the time of screening, support remains available whenever they are.
How We Show Up
Communicate: We clearly explain the program, how information is used, and the benefits available to every New Yorker we serve
Screen: We administer the AHC screening tool in a private, one-on-one setting – in person, by phone, or via telehealth
Connect: We bridge individuals to community-based organizations and services that address their identified needs
