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. Social Care Networks (SCNs) in New York State represent a fundamental shift in healthcare delivery by addressing both medical needs and social determinants of health. These integrated networks serve as essential infrastructure connecting healthcare providers, community organizations, and social service agencies across the state. Through systematic coordination of resources and services, SCNs are reshaping how healthcare organizations approach population health management and preventive care. This analysis examines the current state of SCNs in New York, their operational frameworks, implementation strategies, and their role in transforming community health outcomes.
The Structure and Framework of Social Care Networks in New York
What are Social Care Networks (SCNs)?
SOURCE: Adopted from Medicaid Section 1115(a) Waiver – Overview of Social Care Networks (SCNs). November, 2024.
Social Care Networks (SCNs) represent integrated systems that connect healthcare providers, social service organizations, and community resources to deliver comprehensive care solutions for Medicaid members. These networks address both medical needs and social determinants of health through coordinated service delivery and resource sharing.
The foundational architecture of New York’s SCNs consists of three core components. Primary healthcare providers, including hospitals, clinics, and physician practices, form the clinical foundation. Community-based organizations (CBOs) providing social services represent the second component. The third component comprises the technical infrastructure and data systems that enable seamless coordination between all participants. Integration mechanisms within New York’s SCNs typically follow a hub-and-spoke operational model. Large healthcare institutions or managed care organizations generally serve as central hubs, coordinating with multiple partner organizations that provide specialized services. This model enables efficient resource allocation and streamlined service delivery across the network.
The Objectives of the SCNs
There are 5 major objectives established by NYS Department of Health (DOH):
- Increase capacity to identify unmet needs and navigate Members to health related social need (HRSN) services
- Reach a broader set of populations (e.g., pregnant persons, individuals with serious mental illness or substance use disorder) with enhanced social care services
- Facilitate Medicaid reimbursement for HRSN services (e.g., meal delivery, home modifications, transportation)
- Support system integration of physical, behavioral, and social care services and improve Member experience
- Facilitate cross-sector data sharing via tech platform to improve Member experience and enable measurement of impact of services on health outcomes
Target Population for SCN and HRSN
Participants must meet all three criteria established:
- Are enrolled in Medicaid Managed Care
- Demonstrate one or more unmet needs
- Meet Meet criteria for 1 or more enhanced service populations
- Members with substance use disorder and/or serious mental illness
- Members with intellectual and developmental disabilities
- Pregnant or postpartum persons
- Members recently released from incarceration and have chronic health condition(s)’
- Youth in care (e.g., foster care, juvenile justice, kinship care) who are high risk
- Children under six who are at high risk and children under 18 with chronic health conditions
- Frequent health care users (e.g., emergency room, hospital stays, transitioning from an institutional setting)
- Members enrolled in a Health Home
Tips: Additional clinical criteria may be evaluated for certain enhanced HRSN services
SOCIAL CARE NETWORK (SCN) ECOSYSTEM
Social Care Network (SCN) Ecosystem represents the comprehensive infrastructure of interconnected healthcare and social service entities working together to address both medical and social determinants of health. This network structure creates a cohesive system that enables efficient resource sharing, coordinated care delivery, and improved community health outcomes through systematic collaboration.
SOURCE: Adopted from Medicaid Section 1115(a) Waiver – Overview of Social Care Networks (SCNs). November, 2024.
Examples of stakeholders in SCN Ecosystem:
Regional SCN Lead Entity: Develop network of social care service providers to conduct health-related social needs (HRSN) screening, navigation, and delivery of social care services; reimburse HRSN service providers for services delivery; deploy shared technology platform
HRSN service providers: Conduct screening, navigate Members to existing and/or enhanced services, deliver HRSN services to Members
Health care providers: Conduct HRSN screening and navigate Members to existing and/or enhanced HRSN service
Managed Care Organizations (MCOs): Provide information on Medicaid Members through secure channels to identify who may benefit from and be eligible for HRSN services, and support reimbursement of HRSN services via payment flow to SCNs
Other ecosystem partners: Refer Members to SCN and coordinate with SCN on service navigation and delivery
New York State has established 9 regional Social Care Network Lead Entities who are responsible for building a robust Network of Community-Based Organizations (CBOs) and other organizations providing health-related social needs services and coordinating with health care providers (inclusive of behavioral health and primary care providers). Together, each Social Care Network is responsible for ensuring that there is a seamless, consistent, coordinated, end-to-end process in their region for Screening, Navigation, and delivery of health-related social needs services
Social Care Network (SCN) Lead Entities serve as the central coordinators of regional healthcare and social service networks, with five essential responsibilities that define their operations.
Roles of SCN Lead Entities include:
- Form partnerships within the regional ecosystem to screen Medicaid Members for HRSN, navigate to services, and close the loop on referrals
- Organize and coordinate a network of diverse and culturally competent HRSN service providers, including community-based organizations (CBOs) and other partners
- Pay HRSN service providers for services delivered
- Facilitate data-sharing to support HRSN service navigation and delivery
- Establish a leadership team that reflects the unique needs of the region
Data systems and technology infrastructure serve as the backbone of effective Social Care Networks, fulfilling several critical functions that enable coordinated care delivery and network operations.
Roles of Data and Technology include:
- Screening: Embedded Accountable Health Communities (AHC) HRSN screening tool
- Eligibility Assessment: Ability to use health plan data to determine Member eligibility for enhanced HRSN services
- Navigation and closed loop Referrals: Ability to send and close loop on referrals to ensure services were delivered
- Network Management: Up-to-date network of HRSN service providers and key information about them
- Fiscal Management: Ability to submit social care claims and issue reimbursement to HRSN service providers
Enhanced Health-Related Social Needs (HRSN) Services
How are SCNs implemented?
SOURCE: Adopted from Medicaid Section 1115(a) Waiver – Overview of Social Care Networks (SCNs). November, 2024.
Screening and navigation are essential for the identification of targeted population for HRSN services. These processes ensure accurate identification of needs and efficient connection to appropriate services, forming the cornerstone of effective care coordination.
Effective screening protocols:
- Enable early identification of social needs before they escalate into health crises
- Provide standardized assessment of Health-Related Social Needs (HRSN)
- Create baseline data for tracking intervention effectiveness
- Support resource allocation and service planning
- Facilitate preventive care approaches
Navigation services serve as the bridge between identified needs and available resources. These services:
- Reduce barriers to accessing care and support services
- Ensure appropriate resource utilization
- Increase likelihood of successful service connections
- Support continuous care coordination
- Enable effective follow-up and outcome tracking
There are four major categories of HRSN services provided at this point. Examples of HRSN services:
- Nutrition: nutrition counseling/education, medically tailored meal, food prescription, etc.
- Housing: medically necessary home accessibility/safety modification (handrails, ramps, electronic door opener, etc.), Medically necessary home remediation (mold/pest, ventilation, AC, heater, etc.).
- Social Care Management
- Transportation: public or private transportation for members who has been referred to 1. Housing appointments 2.Nutrition class 3. Pick up of food prescription box
SOURCE: Adopted from Medicaid Section 1115(a) Waiver – Overview of Social Care Networks (SCNs). November, 2024.
How to access SCNs?
- Reach out to your regional SCN Lead Entity for information on how to participate, including how to join an SCN(s) – note there is no deadline to join, and Networks will be built on an ongoing basis
- Share information with colleagues and partners who may be interested in learning more or participating in a SCN
- Share information with Medicaid Members to help connect them to an SCN once service delivery begins
- Share input and feedback with SCN lead entities and OHIP, to support overall program success during and beyond the demonstration period
- Stay in touch on program updates on NYSDOH
Future Developments in New York’s SCN Landscape
The landscape of Social Care Networks in New York continues to evolve, shaped by technological advancements, policy reforms, and expanding integration opportunities. Several key developments are transforming how these networks operate and deliver services.
Technological innovations are significantly impacting network management capabilities. Advanced data analytics platforms are enabling more sophisticated population health management, while artificial intelligence tools are improving referral matching and resource allocation. Cloud-based infrastructure is enhancing data sharing capabilities between providers, enabling more seamless care coordination across the network.
Policy developments are reshaping the SCN framework. The continued emphasis on value-based care models is driving greater integration between healthcare and social services. State initiatives focusing on health equity are expanding the scope of services that SCNs must coordinate. Regulatory frameworks are adapting to support more comprehensive data sharing while maintaining privacy and security standards.
Service integration opportunities are expanding across several domains:
- Mental health and substance use disorder treatment integration
- Housing stability programs
- Food security initiatives
- Transportation coordination services
- Employment support programs
- Educational resource access
Strategic planning considerations for network evolution focus on several key areas:
- Infrastructure scalability to support growing service demands
- Interoperability enhancement between different technology platforms
- Workforce development to support expanding service coordination
- Sustainable funding models to support long-term operations
- Quality measurement frameworks for evaluating network effectiveness
As these networks mature, emphasis is being placed on developing standardized metrics for measuring success and demonstrating value. This includes tracking both health outcomes and social impact indicators, essential for securing continued funding and support.
The future of SCNs in New York points toward more integrated, technologically advanced networks capable of addressing increasingly complex social care needs while maintaining operational efficiency and service quality. Success will depend on the ability to adapt to changing community needs while leveraging new technologies and policy frameworks effectively.
References:
NYSDOH. (2024). New York Health Equity Reform (NYHER) 1115 Waiver Program – Overview of Social Network Cares (SNCs). https://www.health.ny.gov/health_care/medicaid/redesign/sdh/scn/docs/overview.pdf
Social Care Networks. (2024). Ny.gov. https://www.health.ny.gov/health_care/medicaid/redesign/sdh/scn/
Social Determinants of Mental Health among New York City Adults. (n.d.). https://www.nyc.gov/assets/doh/downloads/pdf/epi/databrief139.pdf