The Social Care Network
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ACT Care Foundation is a proud participant in the Brooklyn, Queens, Manhattan, and Staten Island Social Care Networks (SCNs). We offer Health Related Social Needs (HRSN) Screenings, Care Management and Navigation as well as community/federal referrals to all Medicaid Members, and the following services to eligible Enhanced Medicaid Members:
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Two Levels of ServiceUnder the Social Care Network, Medicaid Members are split into two levels of need:
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Am I or a loved one Enhanced?
Medicaid High Utilizers(1) Five or more Emergency Department visits within the last 12 months; or
(2) Four or more Emergency Department visits and one or more Hospital Inpatient stays within the last 12 months; or (3) Two or more Hospital Inpatient stays within the last 12 months; NYS Health HomeIndividuals enrolled in a NYS designated Health Home that currently includes individuals with HIV/AIDS, Serious Mental Illness, Serious Emotional Disturbance, Complex Trauma, Sickle Cell Disease, or two or more chronic conditions (such as, diabetes, congestive heart failure (CHF), chronic kidney disease, chronic obstructive pulmonary disease (COPD), pre-diabetes, obesity, hypertension, malignancies (cancer), asthma or Substance Use Disorder (SUD) ).
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Individuals with Serious Mental IllnessIndividuals with persistent, disabling, progressive or life-threatening mental health condition that requires treatment and/or supports in order to be stabilized, prevent the condition from worsening, or maintain health goals. It includes those with a mental health diagnosis, such as schizophrenia, bipolar disorder, as well as those at risk of suicide
High-risk Youth Under 18A child under 18 who struggles with one of the following:
(1) A chronic condition (e.g., behavioral health condition, developmental delay, chronic or life-threatening allergies, physical disability, and asthma. (2) Child maltreatment as defined by the CDC Children and Youth with Special Healthcare Need. (3) Low birth weight of <2500 grams; (4) A health condition, including behavioral health and developmental syndromes, stemming from trauma, child abuse, and neglect Pregrnant/Post-PartumPregnant and up to 12 months postpartum from the date of delivery, miscarriage, or termination
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Individuals with Substance Use DisorderSUD from all types of substance use that interferes with being able to meet life’s responsibilities, interferes with physical health, or is in an illegal substance.
Individuals with an Intellectual or Developmental DisabilityIncludes a diagnosis of an intellectual or developmental disability, such as Autism Spectrum Disorder, Cerebral Palsy, Epilepsy, Prader-Willi syndrome, a genetic disorder that results in I/DD, Fetal Alcohol Syndrome, untreated inherited metabolic disorders, familial dysautonomia, and chronic neurological disorders.
Post-Release Criminal Justice-Involved Population with chronic conditions, SUD, or chronic Hepatitis-CIndividuals who are up to 90 days post-release from incarceration and have a chronic condition, Substance Use Disorder or hepatitis C.
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