Table 5-3: Select required data elements for Screenings conducted outside the SCN IT Platform
- Table also available in Portable Document Format (PDF)
A comprehensive list of Screening data elements required for submission of the flat file/csv conducted outside the SCN IT Platform can be obtained from the NYeC website. All required fields must be completed to receive Screening reimbursement.
| Item | Question | Response |
|---|---|---|
| Member Responses | ||
| Question 0* | We use this survey to understand needs our [Members / patients / clients] have which could interfere with good health. We may share your answers with your other healthcare providers, and with your health plan and social services organizations, so they can determine if you qualify for any free non-medical services that could be helpful. Please check this box if you agree to continue. You can choose not to answer this survey, but we can only check for services if you do answer. | Permit |
| Deny | ||
| NYS AHC HRSN Tool | 1. What is your living situation today?* | I have a steady place to live |
| I have a place to live today, but I am worried about losing it in the future | ||
| I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) | ||
| 2. Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY* | Pests such as bugs, ants, or mice | |
| Mold | ||
| Lead paint or pipes | ||
| Lack of heat | ||
| Oven or stove not working | ||
| Smoke detectors missing or not working | ||
| Water leaks | ||
| None of the above | ||
| 3. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home* | Yes | |
| No | ||
| Already shut off | ||
| 4. Within the past 12 months, you worried that your food would run out before you got money to buy more.* | Often true | |
| Sometimes true | ||
| Never true | ||
| 5. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.*. | Often true | |
| Sometimes true | ||
| Never true | ||
| Yes | ||
| 6. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?* | No | |
| 7. Do you want help finding or keeping work or a job?* | Yes, help finding work | |
| Yes, help keeping work | ||
| I do not need or want help | ||
| 8. Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.* . | Yes | |
| No | ||
| 9. How often does anyone, including family and friends, physically hurt you? | Never (1) | |
| Rarely (2) | ||
| Sometimes (3) | ||
| Fairly Often (4) | ||
| Frequently (5) | ||
| 10. How often does anyone, including family and friends, insult or talk down to you? | Never (1) | |
| Rarely (2) | ||
| Sometimes (3) | ||
| Fairly Often (4) | ||
| Frequently (5) | ||
| 11. How often does anyone, including family and friends, threaten you with harm? | Never (1) | |
| Rarely (2) | ||
| Sometimes (3) | ||
| Fairly Often (4) | ||
| Frequently (5) | ||
| 12. How often does anyone, including family and friends, scream or curse at you? | Never (1) | |
| Rarely (2) | ||
| Sometimes (3) | ||
| Fairly Often (4) | ||
| Frequently (5) | ||
| 13. Safety Score | Sum of response values 9-12 | |
*Questions 0-8 requires a response from the member. A Member or the person conducting the screening can elect to skip questions 9-12 of the screening questions if it is not a safe or appropriate environment.
