Health-Related Social Needs (HRSN) Benefit

Climate Services: Available now! Receive help to get health-related air conditioners, heaters, air filters, portable power supplies, and mini fridges to store medication.

Housing Services: Since November 1, 2024, Housing-Related support will be available to eligible individuals who are at-risk of losing their current housing. The aim of these services is to support well-being by preventing homelessness, sustaining current housing and supporting tenancy case management services during times of housing insecurity.

HRSN Covered Benefits include: 

• Rent Assistance for up to 6 months including past due months.
• Utilities set up and costs up to 6 months including past due amounts (must be receiving rental assistance to receive utility assistance).
• Tenancy Services (housing case management) for up to 18 months are crucial to support individuals maintain their housing and are offered to members who qualify for any of the other HRSN housing services. Tenancy Services can also be authorized as a stand-alone service.
• Medically-necessary home accessibility modifications and remediations, such as ramp and grab bar installation, pest control, heavy duty cleaning, and hotel costs for members who need temporarily move so that work can be completed in home.
• Storage Fees for members who need to relocate while home modification or remediation is completed.
• Additional benefits may be added in the future.

Eligibility for HRSN Rent Assistance, Utilities Assistance, & Tenancy Services:

To qualify, a Member must meet all of the following criteria:

1. OHP Member and YCCO A or B Member who:

• Is currently housed,
• Needs support staying in home due to inability to pay rent, AND
• Holds a lease or written agreement with their landlord

2. Is at risk of becoming homeless:   

• Has an income that is 30% or less than the area median income in their area AND
• Lacks sufficient resources or support network to prevent homelessness

3. Has at least one Housing Clinical Risk Factor

• Complex behavioral health condition
• Developmental disability
• Complex physical health condition
• Needs assistance with Activities of Daily Living/Instrumental Activities of Daily Living or is eligible for Long Term Services and Supports
• Current or past interpersonal violence experience
• Repeated emergency department use (2 or more visits in a 6-month period)
• Repeated crisis encounters
• Currently pregnant or 12 months postpartum and at risk of certain clinical factors
• Less than six years of age and at risk of certain clinical factors
• More than 65 years of age and at risk of certain clinical factors

Eligibility for HRSN Home Modification/Remediation’s:

1. Current OHP Member and YCCO A or B Member and has at least one Housing Clinical Factor

• Complex behavioral health condition
• Developmental disability
• Complex physical health conditions
• Assistance with Activities of Daily Living/Instrumental Activities of Daily Living or is eligible for Long Term Services and Supports
• Current or past interpersonal violence experience
• Repeated emergency department use (2+ visits within 6 months)
• Repeated crisis encounters
• Currently pregnant or 12 months postpartum and at risk of certain clinical factors
• Less than six years of age and at risk of certain clinical factors
• More than 65 years of age and at risk of certain clinical factors

2. Belongs to an HRSN covered Population

• Adults and Youth Released from Incarceration
• Individuals currently or previously involved in Oregon’s Child Welfare system
• Individuals Transitioning to Dual Medicaid and Medicare Status
• Individuals who meet the At-Risk of Homeless; or
• Young Adults with Special HealthCare Needs ages 19 and 20(starting January 2025)
• Adults and Youth Discharged from an HRSN Eligible Behavioral Health Facility:
  • Acute Care Psychiatric Hospitals
  • Institution for Mental Diseases
  • Integrated Psychiatric Residential Treatment Facilities and Residential Substance Use Disorders
  • Residential Treatment Facilities (RTF), Residential Treatment Homes (RTH), and Secure Residential Treatment Facilities (SRTF)
  • Psychiatric Residential Treatment Facilities (PRTF)
  • Residential Substance Use Disorders Treatment Programs

3. Additional Eligibility Requirements

• Member must need the home modification or remediation to help prevent their health condition
• Member must receive landlord approval for home modification or remediation

Food Benefits (available in January 2025)

Starting January 1, 2025, the below Nutrition Services will be available to eligible members:

• Medically Tailored Meals (MTM) Assessment-an initial assessment and a reassessment, with a licensed dietician (preferred), or, if not available, a primary care provider, to develop a medically appropriate nutrition care plan specific to HRSN MTM service. This service does not require prior authorization.
• Medically Tailored Meals-provide meals to Members with health-related condition(s) for which nutrition supports would improve health outcomes. The service includes:  preparation and provision of the prescribed meals consistent with the nutrition care plan and delivery of meal. To receive meals, Members must first be assessed by RDN or PCP to develop a medically appropriate nutrition care plan.  Eligibility criteria for MTM Meals follows the same criteria as MTM Assessment.  Meals will delivered to the Member’s home or private residence, which may include shelters that do not provide residents with meals.
• Nutrition Education-any combination of educational strategies designed to motivate and facilitate voluntary adoption of food choices and other food and nutrition-related behaviors conducive to health and well-being. The service can consist of nutrition education or information to an individual or group that offers evidence-based or evidence-informed strategies, and/or meal preparation education.  This service can be provided one-time or on a recurring weekly or monthly basis.  Eligibility criteria for Nutrition Education follows the same criteria as MTM Assessment.  Members eligible for the same service through non-HRSN Medicaid  or Medicare/Medicaid are not eligible for the HRSN Service. g.)Members receiving Medical Nutrition Therapy (MNT) through their Medicare benefit are not eligible for this service.

Assessment for Medically Tailored Meals Criteria Eligibility Requirements: 

1. 1. A current OHP member and Yamhill CCO A or B member
   2. Have experienced one of the following:
      • Adult or youth discharged  from an eligible behavioral health facility, residential mental health and substance use disorder facility, or inpatient psychiatric unit within the past 12 months.
      • Adult or youth released from incarceration within the past 12 months.
      • Involved in Oregon’s child welfare system at some point in member’s life.
      • Transitioning from Medicaid-only to dual coverage (receiving both Medicaid and Medicare) within the next 3 months or past 9 months.
      • Members who are at risk of becoming houseless.
      • Young adult, aged 19-20, with Special Healthcare Needs
   3. Have one Nutrition Clinical Risk Factor:
      • Complex Behavioral Health Need; or,
      • Developmental Disability Need-Member with an Intellectual Disability or Developmental Disability that requires services or supports to achieve and maintain care goals; or,
      • Complex Physical Health Need-Member with a persistent, disabling, progressively or life-threatening physical health condition(s) requiring treatment for stabilization or prevention of exacerbation; or,
      • Needs Assistance with ADLs/IADLs or Eligible for LTSS; or,
      • Interpersonal Violence Experience-Member who is experiencing or has experienced interpersonal violence (IPV), including domestic violence (DV), sexual violence (SV), or psychological violence.
      • Repeated Emergency Department Use and Crisis Encounters-With repeated use of emergency department care of two or more visits in the past (6 months or five or more visits within the past (12) months, or with tow or more crisis encounter in the past (6) months or five (5) or more crisis encounters in the past (12) months, which represents an exacerbation of mental health distress
      • Pregnant/Post Partum-a Member who is currently pregnant or up to 12 months postpartum and currently has a history of, or is a risk of at least one of the following:
        • Infection
        • High-risk pregnancy
        • Pregnancy-related death
        • History of previous pregnancy, delivery, or birth complications
        • Abuse or interpersonal violence
        • Malnutrition
        • Maternal low birth weight of <2500 grams
        • Multiple pregnancy
        • A mental health condition or substance use disorder
        • Significant life stress, adversity, or trauma
      • Children less than 6 years of age and currently has, or has a history of, or at risk for at least one of the following:
        • Malnutrition or at risk of developmental or growth delay or impairment as a result of insufficient nutrition;
        • Child maltreatment as defined by the CDC;
        • Is a child with special healthcare need (CYSHCN);
        • Low birth weight of <2500 grams;
        • Mental Health condition;
        • Significant life or family stress, adversity, or trauma
   4. Adults 65 years of age or older and currently has, or has a history of, or at risk for at least one of the following:
      • Two or more chronic health conditions;
      • Social isolation placing the individual at risk for early death, neurocognitive disorders, sleep disruption, cardiovascular disease, and elder abuse;
      • Malnutrition;
      • Dehydration;
      • Abuse or neglect;
      • Significant life adversity, stress, or trauma
   5. Young Adults with Special Health Care Needs (YSHCN) who are aged 19 to 20, with the following clinical risk factors:
      • Has one ormore complex chronic conditions as identified in the Pediatric Medical Complexity algorithm (PCMA);
      • Has serious emotional disturbance or serious mental health issue indicated by qualifying behavioral health diagnosis;
      • Has a diagnosed intellectual or developmental disability;
      • Has an “Elevated Service Need” or functional limitations as determined by two or more affirmative responses to a screener;
   6. Be experiencing Low Food Security or Very Low Food Security-measured by the U.S. Household Food Security Survey Module:
      • Low Food Security-Reduced quality, variety, or desirability of diet, and little or no indication of reduced food intake.
      • Very Low Food Security: Reports of multiple indications of disrupted eating patterns and reduced food intake.
   7. Be eligible for the HRSN Medically Tailored Meals service

YCAP 

Agency Name: Yamhill Community Action Partnership 

Office Hours: Monday-Friday, 8 am to 5 pm 

HRSN Contact Name: Brittany Hanson 

HRSN Contact Phone: (503) 687-1494 

HRSN Contact Email: anydooryamhill@yamhillcap.org 

Creating Opportunities 

Agency Name: Creating Opportunities 

Office Hours: Office Hours Vary.  M-F 

HRSN Contact Name: Cheryl Cisneros 

HRSN Contact Phone: 503-559-0424 

HRSN Contact Email: support@creatingops.org 

Henderson House 

Agency Name: Henderson House 

Office Hours: 9am – 5pm, Monday – Friday 

HRSN Contact Name: Josie Bartlett 

HRSN Contact Phone: 503-472-0244 x 308 

HRSN Contact Email: Jbartlett@hendersonhouse.org 

Polk County 

Agency Name: Polk County Family & Community Outreach 

Office Hours: Monday-Friday 8am-12pm & 1pm-5pm 

HRSN Contact Name: Katrina Reimann 

HRSN Contact Phone: 503-751-1644 

HRSN Contact Email:  reimann.katrina@co.polk.or.us  

Just Compassion 

Agency Name: Just Compassion EWC 

Office Hours: 8:30am-5:00pm 

HRSN Contact Name: Matt Bunn 

HRSN Contact Phone: 848-333-7232 

HRSN Contact Email: matt@justcompassionewc.com 

Meals on Wheels People 

Agency Name: Meals on Wheels People 

Office Hours: M-Th. 8am-4pm 

HRSN Contact Name: Client Services Team 

HRSN Contact Phone: 503.953.8111 

HRSN Contact Email: intake@mowp.org 

Oregon Wellness Network 

Agency Name: Oregon Wellness Network 

Office Hours: M-F  8 – 5pm 

HRSN Contact Name:  Lavinia Goto 

HRSN Contact Phone:  503-304-3408 

HRSN Contact Email:  health.promotion@nwsds.org 

Helping Hands 

Agency Name: Helping Hands Reentry Outreach Centers 

Office Hours: M-F 9am-5pm 

HRSN Contact Name: Joshua Blomquist 

HRSN Contact Phone: n/a 

HRSN Contact Email: hrsnprogram@helpinghandsreentry.org 

Community Wellness Collective 

Agency Name: Community Wellness Collective (CWC) 

Office Hours: 9-5, Monday through Friday 

HRSN Contact Name: Elizabeth Martinez, Lead PSS/CMR 

HRSN Contact Phone: (503) 200-2923 

HRSN Contact Email: elizabeth@communitywellnesscollective.org