Southern Tier Connect presents housing checklist and housing‑navigator steps to Oneonta committee

Dorothy, a health‑home compliance coordinator from Southern Tier Connect, told the Oneonta Community Wellness Committee on Feb. 5 that her agency has added housing‑related screening questions and a housing checklist to its Health‑Related Social Needs (HRSN) intake and already is moving toward case‑level navigation.

The enhancements, Dorothy said, were designed to surface problems in members' homes — from broken handrails to inoperative smoke detectors — that the agency believes contribute to increased emergency‑department use. “We just implemented it January 1. We've already done 70 something from our caseload,” Dorothy said. She described a triage: one checklist item triggers a supervisor review with the care manager; three or more items prompt referral to a housing navigator who works directly with the care manager to identify repair, relocation or other resources.

The agency serves about 1,300 members across 14 counties as one of seven OPWDD care coordination organizations in New York; the Oneonta office accounts for about 25% of the agency's caseload, staff said. Southern Tier Connect staff said earlier data showed roughly a quarter of their entire caseload visited the emergency room at least once in the prior year. Dorothy said the organization hopes better housing screening and navigation will reduce crises and hospital utilization by addressing home safety and stability earlier.

Southern Tier Connect's intake uses the HRSN (Health‑Related Social Needs) instrument required by OPWDD; staff reported they had expanded it with additional housing and school‑related questions to make responses quicker and more reliable. Dorothy said care management home visits fell from monthly to quarterly before the COVID‑19 pandemic and that mix of in‑person and video contacts now varies by family preference and need. She described the agency as voluntary: members enroll through OPWDD's front door and may choose among care coordination organizations that serve their county.

Committee members asked whether the housing checklist covers people in certified settings (IRAs) and Dorothy clarified the checklist is intended for members in community living arrangements, not those in certified settings because those are overseen by separate agencies. Committee members also discussed pathways for people at risk of eviction, including required application to OPWDD rental subsidy programs; Dorothy said some subsidy lists were closed in neighboring counties and availability varies. She described examples where hoarding or severe household decline led to emergency placement to prevent eviction.

The committee and Southern Tier Connect representatives said they plan to continue data collection through 2025 to produce a fuller picture of housing‑related needs, and staff offered to provide more detailed breakdowns of checklist results by residence type and other variables.

Southern Tier Connect framed the changes as program implementation rather than a legislative action. Committee members encouraged the agency to return with further data and to coordinate with county partners and other local service providers.