HRSN screening and referrals

What is the HRSN screening and referrals service?

HRSN screening and referrals refer to screening, referral, and coordination of health-related social needs services and community resources for individuals to improve and manage their health. Community Care Hub providers work closely with a large network of community partners, community-based organizations (CBOs), and community-based worker/workforce (CBWs) in their region.

HRSN screening and referrals include the following activities

• Establish a network of providers, community partners, and community-based organizations that deliver waiver-funded HRSN services and non-waiver HRSN services of community supports services
• Identify and engage Apple Health clients who are likely to have multiple health and social needs by working closely with managed care organizations (MCOs), providers, and community partners
• Screen client's health and/or health-related social needs (if not already screened by MCOs or providers)
• Check client's eligibility to receive either waiver-funded HRSN service of non-waiver community supports or resources
• Refer clients to providers, community partners, or organization(s) that will address their HRSNs
• Follow-up to ensure clients are connected to services and that interventions are completed
• Track outcomes of clients' receiving services
• Provide technical assistance and capacity support - including infrastructure dollars - to community partners or CBOs that deliver waiver-funded HRSN services, and to their community-based workforce
• Provide navigation assistance through a local, trusted community-based workforce

How can someone receive an HRSN screening and referral?

Navigating the process for accessing HRSN services can be challenging. To ensure that individuals and families receive the support they need, there are several paths for referrals to your local Community Care Hub:

• Direct referrals: These referrals are typically made by healthcare providers, social workers, or community organizations who identify an individuals’ specific needs.
• Community-based organizations referrals: local community organizations can play a role in connecting individuals to the Community Care Hubs and HRSN services.
• Managed care organizations (MCOs) referrals: MCOs frequently serve as key referral pathways for HRSN services.

Additionally, individuals can self-refer if you are in need of HRSN services. Please see the Community Care Hub Referral Pathways flyer for additional information and contact details for each of the nine regional Community Care Hubs.

What are Community Care Hubs?

Community Care Hubs (CCHs), established by Accountable Communities of Health (ACHs), are the only entities that can provide the HRSN screening and referral service.

There are nine regional CCHs across Washington State – each function as a central source for connecting individuals with health-related social needs to appropriate services to address these needs within their region. Under the HRSN screening and referral service, CCHs coordinate HRSN referrals by working closely with community organizations, social service, health care facilities, correctional institutions, and governmental bodies. Trained community-based workers (CBW) provide the screening and referral service.

Along with the nine CCHs, Washington State also has one statewide Native Hub. The Native Hub is a statewide network of Washington Tribes, Indian Health Care Providers (IHCPs), tribal social care service divisions, and Native-led, Native-serving organizations in service to whole-person care coordination.

What are Accountable Communities of Health?

Community Care Hubs were developed by Washington State's Accountable Communities of Health (ACHs). More information can be found on the MTP Accountable Communities of Health webpage.