1.7.1 - release

SHINNYHRSN - Local Development build (v1.7.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## : SHINNY Questionnaires - XML Representation

Active as of 2025-12-09

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    <CodeSystem xmlns="http://hl7.org/fhir">
      <id value="SHINNYQuestionnaires"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem SHINNYQuestionnaires</b></p><a name="SHINNYQuestionnaires"> </a><a name="hcSHINNYQuestionnaires"> </a><p>This case-sensitive code system <code>http://test.shinny.org/us/ny/hrsn/CodeSystem/SHINNYQuestionnaires</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">assessment-approval-questionnaire<a name="SHINNYQuestionnaires-assessment-approval-questionnaire"> </a></td><td>Assessment Approval Questionnaire</td><td>Patient approval to move forward with completing the assessment.</td></tr><tr><td style="white-space:nowrap">assessment-outreach-questionnaire<a name="SHINNYQuestionnaires-assessment-outreach-questionnaire"> </a></td><td>Assessment Outreach Questionnaire</td><td>Information regarding the patient outreach from the SCN for a patient assessment.</td></tr><tr><td style="white-space:nowrap">administrative-questionnaire<a name="SHINNYQuestionnaires-administrative-questionnaire"> </a></td><td>Administrative Questionnaire</td><td>Administrative questions that capture information about the patient's population categorization, specific services needed and/or medical necessities.</td></tr><tr><td style="white-space:nowrap">service-duplication-questionnaire<a name="SHINNYQuestionnaires-service-duplication-questionnaire"> </a></td><td>Service Duplication Questionnaire</td><td>Indicator questions recording whether the patient receives assistance from a variety of programs, as well as other social and healthcare needs.</td></tr><tr><td style="white-space:nowrap">referral-approval-questionnaire<a name="SHINNYQuestionnaires-referral-approval-questionnaire"> </a></td><td>Referral Approval Questionnaire</td><td>Patient approval to move forward with the referral.</td></tr><tr><td style="white-space:nowrap">hrsn-outreach-questionnaire<a name="SHINNYQuestionnaires-hrsn-outreach-questionnaire"> </a></td><td>HRSN Outreach Questionnaire</td><td>Captures the service provider outreach date.</td></tr><tr><td style="white-space:nowrap">scn-outreach-questionnaire<a name="SHINNYQuestionnaires-scn-outreach-questionnaire"> </a></td><td>SCN Outreach Questionnaire</td><td>Captures the service provider outreach date.</td></tr><tr><td style="white-space:nowrap">disability-questionnaire<a name="SHINNYQuestionnaires-disability-questionnaire"> </a></td><td>Disability Questionnaire</td><td>Captures responses about a patient's disability mobility.</td></tr><tr><td style="white-space:nowrap">nys-hrsn-questionnaire<a name="SHINNYQuestionnaires-nys-hrsn-questionnaire"> </a></td><td>NYS HRSN Questionnaire</td><td>NYS Accountable Health Communities (AHC) Health-Related Social Needs Screening (HRSN) tool</td></tr><tr><td style="white-space:nowrap">patient-assessment-approval<a name="SHINNYQuestionnaires-patient-assessment-approval"> </a></td><td>Patient Assessment Approval</td><td>Patient approval to move forward with completing the assessment.</td></tr><tr><td style="white-space:nowrap">administrative-questions<a name="SHINNYQuestionnaires-administrative-questions"> </a></td><td>Administrative Questions</td><td>Administrative questions that verify information about the patient.</td></tr><tr><td style="white-space:nowrap">hrsn-outreach<a name="SHINNYQuestionnaires-hrsn-outreach"> </a></td><td>HRSN Outreach</td><td>Questions regarding the HRSN outreach.</td></tr><tr><td style="white-space:nowrap">assessment-outreach<a name="SHINNYQuestionnaires-assessment-outreach"> </a></td><td>Assessment Outreach</td><td>Questions regarding the assessment outreach.</td></tr><tr><td style="white-space:nowrap">referral-approval<a name="SHINNYQuestionnaires-referral-approval"> </a></td><td>Referral Approval</td><td>Questions regarding the referral approval.</td></tr><tr><td style="white-space:nowrap">scn-outreach<a name="SHINNYQuestionnaires-scn-outreach"> </a></td><td>SCN Outreach</td><td>Questions regarding the SCN outreach.</td></tr><tr><td style="white-space:nowrap">service-duplication-questions<a name="SHINNYQuestionnaires-service-duplication-questions"> </a></td><td>Service Duplication Questions</td><td>Questions regarding service duplication.</td></tr><tr><td style="white-space:nowrap">disability-questions<a name="SHINNYQuestionnaires-disability-questions"> </a></td><td>Disability Questions</td><td>Captures a collection of screening responses about a patient's mobility and self-care.</td></tr><tr><td style="white-space:nowrap">patient-assessment-approval-indicator<a name="SHINNYQuestionnaires-patient-assessment-approval-indicator"> </a></td><td>Patient Assessment Approval Indicator</td><td>Indicator of whether the patient agreed to move forward with completing the assessment.</td></tr><tr><td style="white-space:nowrap">patient-assessment-outreach-date<a name="SHINNYQuestionnaires-patient-assessment-outreach-date"> </a></td><td>Patient Assessment Outreach Date</td><td>Date that a patient first receives outreach from SCN for assessment follow-up.</td></tr><tr><td style="white-space:nowrap">patient-assessment-outreach-status<a name="SHINNYQuestionnaires-patient-assessment-outreach-status"> </a></td><td>Patient Assessment Outreach Status</td><td>What was the final result of the patient assessment outreach? Did the patient get assessed? No response?</td></tr><tr><td style="white-space:nowrap">outreach-method<a name="SHINNYQuestionnaires-outreach-method"> </a></td><td>Outreach Method</td><td>Describes the method of contact used to reach out to the patient.</td></tr><tr><td style="white-space:nowrap">enhanced-population-check<a name="SHINNYQuestionnaires-enhanced-population-check"> </a></td><td>Enhanced Population Check</td><td>Check populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, resulting in SCN request to update covered population categorization with MCO.</td></tr><tr><td style="white-space:nowrap">service-duplication-check<a name="SHINNYQuestionnaires-service-duplication-check"> </a></td><td>Service Duplication Check</td><td>Check populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives services that would inhibit ability to deliver any or all NYHER services.</td></tr><tr><td style="white-space:nowrap">clinical-criteria-check<a name="SHINNYQuestionnaires-clinical-criteria-check"> </a></td><td>Clinical Criteria Check</td><td>Check populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient has the required medical necessity that would satisfy requirement to deliver NYHER service.</td></tr><tr><td style="white-space:nowrap">housing-program<a name="SHINNYQuestionnaires-housing-program"> </a></td><td>Housing Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives or is on any housing waitlists (e.g., HUD. Section 8, local housing authority, or other voucher programs).</td></tr><tr><td style="white-space:nowrap">nutritional-education-program<a name="SHINNYQuestionnaires-nutritional-education-program"> </a></td><td>Nutritional Education Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives nutritional counseling or education.</td></tr><tr><td style="white-space:nowrap">nutritional-services-program<a name="SHINNYQuestionnaires-nutritional-services-program"> </a></td><td>Nutritional Services Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient is actively engaged in a nutrition program.</td></tr><tr><td style="white-space:nowrap">food-service-program<a name="SHINNYQuestionnaires-food-service-program"> </a></td><td>Food Service Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives any home-delivered meals or food services.</td></tr><tr><td style="white-space:nowrap">snapp-program<a name="SHINNYQuestionnaires-snapp-program"> </a></td><td>SNAPP Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in SNAP.</td></tr><tr><td style="white-space:nowrap">wic-program<a name="SHINNYQuestionnaires-wic-program"> </a></td><td>WIC Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in WIC.</td></tr><tr><td style="white-space:nowrap">tanf-program<a name="SHINNYQuestionnaires-tanf-program"> </a></td><td>TANF Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in TANF.</td></tr><tr><td style="white-space:nowrap">transportation-program<a name="SHINNYQuestionnaires-transportation-program"> </a></td><td>Transportation Program</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in Transportation services.</td></tr><tr><td style="white-space:nowrap">medication-requiring-refrigeration<a name="SHINNYQuestionnaires-medication-requiring-refrigeration"> </a></td><td>Medication Requiring Refrigeration</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently prescribed medication, requiring refrigeration for the management of a chronic condition.</td></tr><tr><td style="white-space:nowrap">breast-milk-requiring-refrigeration<a name="SHINNYQuestionnaires-breast-milk-requiring-refrigeration"> </a></td><td>Breast Milk Requiring Refrigeration</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is a pregnant/postpartum persons that require a refrigeration for breast milk.</td></tr><tr><td style="white-space:nowrap">adls-iadls<a name="SHINNYQuestionnaires-adls-iadls"> </a></td><td>ADLS-IADLS</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient currently has Activities of Daily Living (ADLs) &amp; Instrumental Activities of Daily Living (IADLs) needs.</td></tr><tr><td style="white-space:nowrap">medical-respite<a name="SHINNYQuestionnaires-medical-respite"> </a></td><td>Medical Respite</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient meets the qualifications for medical respite (see notes).</td></tr><tr><td style="white-space:nowrap">childcare-assistance<a name="SHINNYQuestionnaires-childcare-assistance"> </a></td><td>Childcare Assistance</td><td>Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient needs assistance with childcare.</td></tr><tr><td style="white-space:nowrap">patient-referral-approval<a name="SHINNYQuestionnaires-patient-referral-approval"> </a></td><td>Patient Referral Approval</td><td>Patient approval to move forward with the referral.</td></tr><tr><td style="white-space:nowrap">hrsn-referral-outreach-date<a name="SHINNYQuestionnaires-hrsn-referral-outreach-date"> </a></td><td>HRSN Referral Outreach Date</td><td>The date/time the HRSN Service Provider conducted outreach to patient, based on accepted referral.</td></tr><tr><td style="white-space:nowrap">scn-referral-outreach-date<a name="SHINNYQuestionnaires-scn-referral-outreach-date"> </a></td><td>SCN Referral Outreach Date</td><td>The date/time the SCN conducted outreach to the patient, based on referral if outreach is not initiated by HRSN Service Provider/Social Service Provider.</td></tr><tr><td style="white-space:nowrap">difficulty-walking-climbing-stairs<a name="SHINNYQuestionnaires-difficulty-walking-climbing-stairs"> </a></td><td>Difficulty Walking Climbing Stairs</td><td>Do you have serious difficulty walking or climbing stairs? (5 years old or older)</td></tr><tr><td style="white-space:nowrap">difficulty-dressing-bathing<a name="SHINNYQuestionnaires-difficulty-dressing-bathing"> </a></td><td>Difficulty Dressing Bathing</td><td>Do you have difficulty dressing or bathing? (5 years old or older)</td></tr><tr><td style="white-space:nowrap">medicaid-high-utilizer<a name="SHINNYQuestionnaires-medicaid-high-utilizer"> </a></td><td>Medicaid High Utilizer</td><td/></tr><tr><td style="white-space:nowrap">nys-health-home<a name="SHINNYQuestionnaires-nys-health-home"> </a></td><td>Individuals Enrolled in a NYS Health Home</td><td/></tr><tr><td style="white-space:nowrap">pregnant-postpartum<a name="SHINNYQuestionnaires-pregnant-postpartum"> </a></td><td>Pregnant and Postpartum Persons</td><td/></tr><tr><td style="white-space:nowrap">children-high-risk<a name="SHINNYQuestionnaires-children-high-risk"> </a></td><td>High-Risk Children Under 18 Years Old</td><td/></tr><tr><td style="white-space:nowrap">intellectual-developmental-disability<a name="SHINNYQuestionnaires-intellectual-developmental-disability"> </a></td><td>Individuals with an Intellectual or Developmental Disability</td><td/></tr><tr><td style="white-space:nowrap">released-chronic-condition<a name="SHINNYQuestionnaires-released-chronic-condition"> </a></td><td>Individuals with a Chronic Condition Released from Incarceration in the Past 90 Days</td><td/></tr><tr><td style="white-space:nowrap">other-eligible-population<a name="SHINNYQuestionnaires-other-eligible-population"> </a></td><td>Other Eligible Population</td><td/></tr><tr><td style="white-space:nowrap">high-risk-nutrition<a name="SHINNYQuestionnaires-high-risk-nutrition"> </a></td><td>High Risk Children Under 18 Nutrition Only</td><td/></tr><tr><td style="white-space:nowrap">supportive-housing<a name="SHINNYQuestionnaires-supportive-housing"> </a></td><td>Supportive Housing</td><td/></tr><tr><td style="white-space:nowrap">healthy-homes<a name="SHINNYQuestionnaires-healthy-homes"> </a></td><td>Healthy Homes</td><td/></tr><tr><td style="white-space:nowrap">nutritional-counseling<a name="SHINNYQuestionnaires-nutritional-counseling"> </a></td><td>Nutritional Counseling</td><td/></tr><tr><td style="white-space:nowrap">medical-tailored-meals<a name="SHINNYQuestionnaires-medical-tailored-meals"> </a></td><td>Medically Tailored Meals (MTM) In-lieu of Services (ILOS)</td><td/></tr><tr><td style="white-space:nowrap">health-home-enrollment<a name="SHINNYQuestionnaires-health-home-enrollment"> </a></td><td>Health Home Enrollment (under Enhanced Populations)</td><td/></tr><tr><td style="white-space:nowrap">opwdd-waiver<a name="SHINNYQuestionnaires-opwdd-waiver"> </a></td><td>Office for Persons with Developmental Disabilities (OPWDD) Waiver</td><td/></tr><tr><td style="white-space:nowrap">tbi-waiver<a name="SHINNYQuestionnaires-tbi-waiver"> </a></td><td>Traumatic Brain Injury (TBI) Waiver</td><td/></tr><tr><td style="white-space:nowrap">nhtd-waiver<a name="SHINNYQuestionnaires-nhtd-waiver"> </a></td><td>Nursing Home Transition Diversion (NHTD) Waiver</td><td/></tr><tr><td style="white-space:nowrap">childrens-waiver<a name="SHINNYQuestionnaires-childrens-waiver"> </a></td><td>Childrens Waiver</td><td/></tr><tr><td style="white-space:nowrap">medicaid-advantage-program<a name="SHINNYQuestionnaires-medicaid-advantage-program"> </a></td><td>Medicaid Advantage Program (MAP)</td><td/></tr><tr><td style="white-space:nowrap">mltcp<a name="SHINNYQuestionnaires-mltcp"> </a></td><td>Partial Capitation Managed Long-Term Care (MLTCP)</td><td/></tr><tr><td style="white-space:nowrap">chronic-condition<a name="SHINNYQuestionnaires-chronic-condition"> </a></td><td>Chronic Condition</td><td/></tr><tr><td style="white-space:nowrap">uncontrolled-asthma<a name="SHINNYQuestionnaires-uncontrolled-asthma"> </a></td><td>Uncontrolled Asthma</td><td/></tr><tr><td style="white-space:nowrap">nutrition-therapy<a name="SHINNYQuestionnaires-nutrition-therapy"> </a></td><td>Enteral or Parenteral Nutrition Therapy</td><td/></tr><tr><td style="white-space:nowrap">current-institutional-setting<a name="SHINNYQuestionnaires-current-institutional-setting"> </a></td><td>Currently in an Institutional Setting</td><td/></tr><tr><td style="white-space:nowrap">heat-related-illness<a name="SHINNYQuestionnaires-heat-related-illness"> </a></td><td>Heat-Related Illness Requiring an ER or UC Visit</td><td/></tr><tr><td style="white-space:nowrap">cold-related-illness<a name="SHINNYQuestionnaires-cold-related-illness"> </a></td><td>Cold-Related Illness Requiring an ER or UC Visit</td><td/></tr><tr><td style="white-space:nowrap">thermoregulation-interference<a name="SHINNYQuestionnaires-thermoregulation-interference"> </a></td><td>Conditions and Medications Interfering with Thermoregulation</td><td/></tr><tr><td style="white-space:nowrap">none-of-the-above<a name="SHINNYQuestionnaires-none-of-the-above"> </a></td><td>None of the Above</td><td/></tr><tr><td style="white-space:nowrap">asked-declined<a name="SHINNYQuestionnaires-asked-declined"> </a></td><td>Asked But Declined</td><td/></tr><tr><td style="white-space:nowrap">phone<a name="SHINNYQuestionnaires-phone"> </a></td><td>Phone</td><td/></tr><tr><td style="white-space:nowrap">fax<a name="SHINNYQuestionnaires-fax"> </a></td><td>Fax</td><td/></tr><tr><td style="white-space:nowrap">email<a name="SHINNYQuestionnaires-email"> </a></td><td>Email</td><td/></tr><tr><td style="white-space:nowrap">pager<a name="SHINNYQuestionnaires-pager"> </a></td><td>Pager</td><td/></tr><tr><td style="white-space:nowrap">url<a name="SHINNYQuestionnaires-url"> </a></td><td>URL</td><td/></tr><tr><td style="white-space:nowrap">sms<a name="SHINNYQuestionnaires-sms"> </a></td><td>SMS</td><td/></tr><tr><td style="white-space:nowrap">other<a name="SHINNYQuestionnaires-other"> </a></td><td>Other</td><td/></tr></table></div>
      </text>
      <url
           value="http://test.shinny.org/us/ny/hrsn/CodeSystem/SHINNYQuestionnaires"/>
      <version value="1.7.1"/>
      <name value="SHINNYQuestionnaires"/>
      <title value="SHINNY Questionnaires"/>
      <status value="active"/>
      <experimental value="false"/>
      <date value="2025-12-09T09:01:49-05:00"/>
      <publisher value="shinny"/>
      <contact>
        <name value="shinny"/>
        <telecom>
          <system value="url"/>
          <value value="https://test.shinny.org/us/ny/hrsn.index.html"/>
        </telecom>
      </contact>
      <description value="Codes for terms found in SHIN-NY Questionnaires"/>
      <caseSensitive value="true"/>
      <content value="complete"/>
      <count value="77"/>
      <concept>
        <code value="assessment-approval-questionnaire"/>
        <display value="Assessment Approval Questionnaire"/>
        <definition
                    value="Patient approval to move forward with completing the assessment."/>
      </concept>
      <concept>
        <code value="assessment-outreach-questionnaire"/>
        <display value="Assessment Outreach Questionnaire"/>
        <definition
                    value="Information regarding the patient outreach from the SCN for a patient assessment."/>
      </concept>
      <concept>
        <code value="administrative-questionnaire"/>
        <display value="Administrative Questionnaire"/>
        <definition
                    value="Administrative questions that capture information about the patient's population categorization, specific services needed and/or medical necessities."/>
      </concept>
      <concept>
        <code value="service-duplication-questionnaire"/>
        <display value="Service Duplication Questionnaire"/>
        <definition
                    value="Indicator questions recording whether the patient receives assistance from a variety of programs, as well as other social and healthcare needs."/>
      </concept>
      <concept>
        <code value="referral-approval-questionnaire"/>
        <display value="Referral Approval Questionnaire"/>
        <definition value="Patient approval to move forward with the referral."/>
      </concept>
      <concept>
        <code value="hrsn-outreach-questionnaire"/>
        <display value="HRSN Outreach Questionnaire"/>
        <definition value="Captures the service provider outreach date."/>
      </concept>
      <concept>
        <code value="scn-outreach-questionnaire"/>
        <display value="SCN Outreach Questionnaire"/>
        <definition value="Captures the service provider outreach date."/>
      </concept>
      <concept>
        <code value="disability-questionnaire"/>
        <display value="Disability Questionnaire"/>
        <definition
                    value="Captures responses about a patient's disability mobility."/>
      </concept>
      <concept>
        <code value="nys-hrsn-questionnaire"/>
        <display value="NYS HRSN Questionnaire"/>
        <definition
                    value="NYS Accountable Health Communities (AHC) Health-Related Social Needs Screening (HRSN) tool"/>
      </concept>
      <concept>
        <code value="patient-assessment-approval"/>
        <display value="Patient Assessment Approval"/>
        <definition
                    value="Patient approval to move forward with completing the assessment."/>
      </concept>
      <concept>
        <code value="administrative-questions"/>
        <display value="Administrative Questions"/>
        <definition
                    value="Administrative questions that verify information about the patient."/>
      </concept>
      <concept>
        <code value="hrsn-outreach"/>
        <display value="HRSN Outreach"/>
        <definition value="Questions regarding the HRSN outreach."/>
      </concept>
      <concept>
        <code value="assessment-outreach"/>
        <display value="Assessment Outreach"/>
        <definition value="Questions regarding the assessment outreach."/>
      </concept>
      <concept>
        <code value="referral-approval"/>
        <display value="Referral Approval"/>
        <definition value="Questions regarding the referral approval."/>
      </concept>
      <concept>
        <code value="scn-outreach"/>
        <display value="SCN Outreach"/>
        <definition value="Questions regarding the SCN outreach."/>
      </concept>
      <concept>
        <code value="service-duplication-questions"/>
        <display value="Service Duplication Questions"/>
        <definition value="Questions regarding service duplication."/>
      </concept>
      <concept>
        <code value="disability-questions"/>
        <display value="Disability Questions"/>
        <definition
                    value="Captures a collection of screening responses about a patient's mobility and self-care."/>
      </concept>
      <concept>
        <code value="patient-assessment-approval-indicator"/>
        <display value="Patient Assessment Approval Indicator"/>
        <definition
                    value="Indicator of whether the patient agreed to move forward with completing the assessment."/>
      </concept>
      <concept>
        <code value="patient-assessment-outreach-date"/>
        <display value="Patient Assessment Outreach Date"/>
        <definition
                    value="Date that a patient first receives outreach from SCN for assessment follow-up."/>
      </concept>
      <concept>
        <code value="patient-assessment-outreach-status"/>
        <display value="Patient Assessment Outreach Status"/>
        <definition
                    value="What was the final result of the patient assessment outreach? Did the patient get assessed? No response?"/>
      </concept>
      <concept>
        <code value="outreach-method"/>
        <display value="Outreach Method"/>
        <definition
                    value="Describes the method of contact used to reach out to the patient."/>
      </concept>
      <concept>
        <code value="enhanced-population-check"/>
        <display value="Enhanced Population Check"/>
        <definition
                    value="Check populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, resulting in SCN request to update covered population categorization with MCO."/>
      </concept>
      <concept>
        <code value="service-duplication-check"/>
        <display value="Service Duplication Check"/>
        <definition
                    value="Check populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives services that would inhibit ability to deliver any or all NYHER services."/>
      </concept>
      <concept>
        <code value="clinical-criteria-check"/>
        <display value="Clinical Criteria Check"/>
        <definition
                    value="Check populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient has the required medical necessity that would satisfy requirement to deliver NYHER service."/>
      </concept>
      <concept>
        <code value="housing-program"/>
        <display value="Housing Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives or is on any housing waitlists (e.g., HUD. Section 8, local housing authority, or other voucher programs)."/>
      </concept>
      <concept>
        <code value="nutritional-education-program"/>
        <display value="Nutritional Education Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives nutritional counseling or education."/>
      </concept>
      <concept>
        <code value="nutritional-services-program"/>
        <display value="Nutritional Services Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient is actively engaged in a nutrition program."/>
      </concept>
      <concept>
        <code value="food-service-program"/>
        <display value="Food Service Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment, identifying if patient currently receives any home-delivered meals or food services."/>
      </concept>
      <concept>
        <code value="snapp-program"/>
        <display value="SNAPP Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in SNAP."/>
      </concept>
      <concept>
        <code value="wic-program"/>
        <display value="WIC Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in WIC."/>
      </concept>
      <concept>
        <code value="tanf-program"/>
        <display value="TANF Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in TANF."/>
      </concept>
      <concept>
        <code value="transportation-program"/>
        <display value="Transportation Program"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently engaged in Transportation services."/>
      </concept>
      <concept>
        <code value="medication-requiring-refrigeration"/>
        <display value="Medication Requiring Refrigeration"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is currently prescribed medication, requiring refrigeration for the management of a chronic condition."/>
      </concept>
      <concept>
        <code value="breast-milk-requiring-refrigeration"/>
        <display value="Breast Milk Requiring Refrigeration"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient is a pregnant/postpartum persons that require a refrigeration for breast milk."/>
      </concept>
      <concept>
        <code value="adls-iadls"/>
        <display value="ADLS-IADLS"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient currently has Activities of Daily Living (ADLs) &amp; Instrumental Activities of Daily Living (IADLs) needs."/>
      </concept>
      <concept>
        <code value="medical-respite"/>
        <display value="Medical Respite"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient meets the qualifications for medical respite (see notes)."/>
      </concept>
      <concept>
        <code value="childcare-assistance"/>
        <display value="Childcare Assistance"/>
        <definition
                    value="Indicator, populated by entity, conducting the assessment. Captures patient response during the HRSN assessment,  identifying if patient needs assistance with childcare."/>
      </concept>
      <concept>
        <code value="patient-referral-approval"/>
        <display value="Patient Referral Approval"/>
        <definition value="Patient approval to move forward with the referral."/>
      </concept>
      <concept>
        <code value="hrsn-referral-outreach-date"/>
        <display value="HRSN Referral Outreach Date"/>
        <definition
                    value="The date/time the HRSN Service Provider conducted outreach to patient, based on accepted referral."/>
      </concept>
      <concept>
        <code value="scn-referral-outreach-date"/>
        <display value="SCN Referral Outreach Date"/>
        <definition
                    value="The date/time the SCN conducted outreach to the patient, based on referral if outreach is not initiated by HRSN Service Provider/Social Service Provider."/>
      </concept>
      <concept>
        <code value="difficulty-walking-climbing-stairs"/>
        <display value="Difficulty Walking Climbing Stairs"/>
        <definition
                    value="Do you have serious difficulty walking or climbing stairs? (5 years old or older)"/>
      </concept>
      <concept>
        <code value="difficulty-dressing-bathing"/>
        <display value="Difficulty Dressing Bathing"/>
        <definition
                    value="Do you have difficulty dressing or bathing? (5 years old or older)"/>
      </concept>
      <concept>
        <code value="medicaid-high-utilizer"/>
        <display value="Medicaid High Utilizer"/>
      </concept>
      <concept>
        <code value="nys-health-home"/>
        <display value="Individuals Enrolled in a NYS Health Home"/>
      </concept>
      <concept>
        <code value="pregnant-postpartum"/>
        <display value="Pregnant and Postpartum Persons"/>
      </concept>
      <concept>
        <code value="children-high-risk"/>
        <display value="High-Risk Children Under 18 Years Old"/>
      </concept>
      <concept>
        <code value="intellectual-developmental-disability"/>
        <display
                 value="Individuals with an Intellectual or Developmental Disability"/>
      </concept>
      <concept>
        <code value="released-chronic-condition"/>
        <display
                 value="Individuals with a Chronic Condition Released from Incarceration in the Past 90 Days"/>
      </concept>
      <concept>
        <code value="other-eligible-population"/>
        <display value="Other Eligible Population"/>
      </concept>
      <concept>
        <code value="high-risk-nutrition"/>
        <display value="High Risk Children Under 18 Nutrition Only"/>
      </concept>
      <concept>
        <code value="supportive-housing"/>
        <display value="Supportive Housing"/>
      </concept>
      <concept>
        <code value="healthy-homes"/>
        <display value="Healthy Homes"/>
      </concept>
      <concept>
        <code value="nutritional-counseling"/>
        <display value="Nutritional Counseling"/>
      </concept>
      <concept>
        <code value="medical-tailored-meals"/>
        <display
                 value="Medically Tailored Meals (MTM) In-lieu of Services (ILOS)"/>
      </concept>
      <concept>
        <code value="health-home-enrollment"/>
        <display value="Health Home Enrollment (under Enhanced Populations)"/>
      </concept>
      <concept>
        <code value="opwdd-waiver"/>
        <display
                 value="Office for Persons with Developmental Disabilities (OPWDD) Waiver"/>
      </concept>
      <concept>
        <code value="tbi-waiver"/>
        <display value="Traumatic Brain Injury (TBI) Waiver"/>
      </concept>
      <concept>
        <code value="nhtd-waiver"/>
        <display value="Nursing Home Transition Diversion (NHTD) Waiver"/>
      </concept>
      <concept>
        <code value="childrens-waiver"/>
        <display value="Childrens Waiver"/>
      </concept>
      <concept>
        <code value="medicaid-advantage-program"/>
        <display value="Medicaid Advantage Program (MAP)"/>
      </concept>
      <concept>
        <code value="mltcp"/>
        <display value="Partial Capitation Managed Long-Term Care (MLTCP)"/>
      </concept>
      <concept>
        <code value="chronic-condition"/>
        <display value="Chronic Condition"/>
      </concept>
      <concept>
        <code value="uncontrolled-asthma"/>
        <display value="Uncontrolled Asthma"/>
      </concept>
      <concept>
        <code value="nutrition-therapy"/>
        <display value="Enteral or Parenteral Nutrition Therapy"/>
      </concept>
      <concept>
        <code value="current-institutional-setting"/>
        <display value="Currently in an Institutional Setting"/>
      </concept>
      <concept>
        <code value="heat-related-illness"/>
        <display value="Heat-Related Illness Requiring an ER or UC Visit"/>
      </concept>
      <concept>
        <code value="cold-related-illness"/>
        <display value="Cold-Related Illness Requiring an ER or UC Visit"/>
      </concept>
      <concept>
        <code value="thermoregulation-interference"/>
        <display
                 value="Conditions and Medications Interfering with Thermoregulation"/>
      </concept>
      <concept>
        <code value="none-of-the-above"/>
        <display value="None of the Above"/>
      </concept>
      <concept>
        <code value="asked-declined"/>
        <display value="Asked But Declined"/>
      </concept>
      <concept>
        <code value="phone"/>
        <display value="Phone"/>
      </concept>
      <concept>
        <code value="fax"/>
        <display value="Fax"/>
      </concept>
      <concept>
        <code value="email"/>
        <display value="Email"/>
      </concept>
      <concept>
        <code value="pager"/>
        <display value="Pager"/>
      </concept>
      <concept>
        <code value="url"/>
        <display value="URL"/>
      </concept>
      <concept>
        <code value="sms"/>
        <display value="SMS"/>
      </concept>
      <concept>
        <code value="other"/>
        <display value="Other"/>
      </concept>
    </CodeSystem>