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TEAMKY Demonstration
Approval Period: January 1, 2025 through December 31, 2029
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Attachment N: HRSN Service Matrix
Target Populations
Service All full-benefit Medicaid eligibles age 18 and over who meet social and clinical risk criteria Housing Services with Room and Board Short-term pre-procedure and/or post- hospitalization housing X Short-term post-transition housing X
Service Eligible Population Social Risk Factor Clinical Criteria for the pop
Housing Services with Room and Board
Short-term pre-procedure housing
All full-benefit Medicaid eligibles age 18 and over who meet social and clinical risk criteria
Individuals who are homeless, or at risk of homelessness Have a primary medical diagnosis, and are at risk of hospitalization and/or readmission with a medical need and: Have a planned medical procedure requiring preparation care, or Have a planned medical treatment (i.e.: chemotherapy treatment) requiring care prior to the treatment
Short-term post-transition housing
All full-benefit Medicaid eligibles age 18 and over who meet social and clinical risk criteria
Individuals who are homeless, or at risk of homelessness Have a primary medical diagnosis, and are at risk of hospitalization and/or readmission with a medical need following discharge from acute care facility or Emergency Department, or Have a planned medical treatment (i.e.: chemotherapy treatment) requiring care following the treatment
Clinical Risk Factor Clinical Criteria Detail
Risk Factor 1 Have a primary medical diagnosis, and are at risk of hospitalization as determined by licensed clinical staff and/or readmission with a medical need: 1) following discharge from acute care facility or Emergency Department, or 2) Have a planned medical procedure requiring preparation care, or Have a planned medical treatment (i.e.: chemotherapy treatment) requiring care prior to or following the treatment
Social Risk Factor Social Criteria Detail Risk Factor 1 Individuals who are homeless, or at risk of homelessness who meet criteria based upon definitions in 24 CFR 91.5, except for the annual income requirement in 24 CFR