Outreach

The Outreach program helps us extend the work we do to assist guests beyond our four walls. We offer basic and enhanced assistance based on an individual’s needs, promoting person-centered, choice-based services that enhance health, housing, and food security. 

Our outreach team is on the streets, at nearby motels and in places people are known to gather – offering basic necessities such as healthy snacks, water, and hygiene supplies. This connection offers the opportunity to form trusting relationships which often lead to enhance care through our NYS Health Home and Medicaid Waiver 1115 care management services or placement in our shelters or housing programs. 

Outreach is often the first step toward stability and the sometimes hardest one to take. 

Health Home: Mobile Care Management

Shelters of Saratoga is a NYS Health Home (NYSHH) provider through Adirondack Health Institute (AHI), which offers ongoing care management services to eligible Medicaid enrollees with a chronic health condition. The goal of Health Home is to stabilize/manage a participant’s chronic condition to avoid burdening the health care system. The Health Home program offers the following services: comprehensive assessments, goal setting, healthcare management, and housing stabilization. Participation in the NYSHH program is voluntary.

Our Health Home care management services are available to enrollees no matter where they are, at home, on the streets, or in shelter. 

Support Offered

Waiver 1115 Program

Shelters of Saratoga participates in the Medicaid Waiver 1115 Social Care Network (SCN) program. As a partner Community Based Organization (CBO), the goal of the program is to provide screening and navigation of Medicaid Members to critical health related social needs (HRSN) services, and provision of those services.

As a CBO we provide direct services that improve health outcomes outside of a clinical setting. Through the Social Care Network, we help Members access support such as:

• Healthy food and medically tailored meals
• Housing stabilization and utility assistance
• Transportation to medical appointments and community resources
• Care navigation and case management
• Behavioral health support
• Benefits enrollment assistance
• Home and environmental modifications

By addressing these social determinants of health, we help reduce barriers that can lead to poor health outcomes, emergency room visits, or avoidable hospitalizations.

Coordinating Care Across Systems

One of the most important functions of CBOs within the Social Care Network is coordination. Community organizations work alongside health care providers, Medicaid Managed Care Organizations, and regional network leaders to ensure individuals receive timely, connected support.

Using shared referral platforms and closed-loop communication systems, CBOs can:

• Receive referrals from health care providers
• Track service delivery and outcomes
• Communicate with care teams
• Follow up with Members to ensure needs are resolved
• Identify additional barriers or unmet needs

This collaborative approach creates a more integrated and person-centered care experience.

Advancing Health Equity

As a CBO we play a critical role in advancing health equity. We understand the systemic challenges many individuals face, including poverty, housing instability, food insecurity, transportation barriers, and language or cultural obstacles.

Our involvement helps ensure services are:

• Accessible
• Culturally responsive
• Community-informed
• Equitable
• Tailored to local needs

By elevating the voice of the community and delivering support where it is needed most, CBOs help create healthier and more resilient communities across New York State.