Social Determinants of Care & Warm Handoff Processes

Social Determinants of Health

Questions Warm Handoff Process Resource Names Phone Number Web Site
Questions to ask: Catholic Charities 304-267-8837 www.catholiccharitieswv.org
Have they been to a food bank already? Child Care Food Program 304-230-1280
Which ones have they been to? Church without Walls Ministries 304-260-9509
Do they want us to help them call? Community Combined Ministries 304-268-8778 www.communitycombined.org
Call with them? Community Networks, Inc. 304-263-3510
C-CAP (Congregational Cooperative Action Project) Loaves & Fishes 304-263-3940
In the last 12 months, did you ever eat less than you
felt you should because there wasn’t enough money What to hand them: Food Assistance at Telamon 304-263-0916
for food? 211 Pocket brochure – highlight with marker the food options Hedgesville United Methodist Church Food Pantry 304-754-8793
Resource list - highlight with marker the food options Good Shepherd Interfaith Volunteer Caregivers 304-876-3325 www.gsivc.org
Salvation Army 304-267-4612 www.salvationarmyusa.org
St. Vincent De Paul 304-671-0569
Warming Hands & Hearts 304-886-1347 www.uwayep.org/ourwork/community-solutions/warminghands-and-hearts
WV WIC (Women, Infants, and Children) 304-267-5477 www.wvdhhr.org
Direct them to: Free Cell Phone for Emergency 911 http://www.americancellphonedrive.org/
DHHR to Regional Resource Connection or Telamon - These provide low income assistance for utility bills Eastern West Virginia Community Foundation 304-264-0353 www.ewvcf.org
Catholic Charities – will provide income assistance
Different churches in Martinsburg - Churches have funds that they distribute to families in need.
In the last 12 months, has your utility company shut off
your service for not paying your bills?
What to hand them:
211 Pocket brochure – highlight with marker the utility assistance options.

Resource list - highlight with marker the utility options

Considerations: Call 211 for assistance

If the worry is that in the next two months they will not have housing, refer to Telamon or Habitat to Humanity. Bethany House (Women & Children) •304-263-6614
•304-263-3510
Community Networks, Inc. 304-263-3510

If the worry is immediate and urgent, then handoff to Alicia at Homeless Coalition. SW/FCOC should call to Alicia at 304-579-5150. Chronic Homeless Program (Telamon)
Are you worried that in the next 2 months you might 304-263-0916 ext. 12
not have housing? Martinsburg Union Rescue Mission (Men) 304-263-6901
What to hand them: Community Networks, Inc 304–263-6614
211 Pocket brochure – highlight with marker the housing options Habitat for Humanity of the Eastern Panhandle 304-263-3154 www.habitatep.org
Home Buyer Education Classes at Telamon 304-263-0916
Resource list - highlight with marker the housing options Martinsburg Housing Authority 304-263-8891
Self-Help Housing (Telamon) 304-263-0916
Do problems getting child-care make it difficult for you With the family, contact DHHR to see if they are eligible for Mountain Heart. Mountain Heart funds childcare cost. DHHR
to work or study?
(leave blank if you do not have children) Care.com
What to hand them:
211 Pocket brochure – highlight with marker any child care options

Resource list - highlight with marker the childcare options

Questions to ask: Check DHHR for medical card eligibility
Do they have Medicare/Medicaid? Free Clinic/ 601 S. Raleigh St
Do they qualify for Medicare/Medicaid? Affordable Care Act – WV MedicaidCHIP Enrollment Coordinator 304-596-2224 ext. 1019
Good Samaritan Free Clinic 304-264-4049 www.goodsamfcwv.org/wordpress
Help them: Health Insurance Premium Payment (HIPP) Program 304-342-1604 www.wvrecovery.com/
In the last 12 months, have you needed to see a If they qualify for Medicare/Medicaid and haven’t applied, help them fill out paperwork online. Healthy Smiles Oral Health Center
doctor, but could not because of the cost? 304-267-0250 www.svms.net/oral-healthcare.php
HIV/AIDS testing and support 304-263-4999, ext 1034 www.svms.net
Send them to Free Clinic – 601 S Raleigh Street, Martinsburg, WV. John D. Good Recovery Center 304-789-3142
Martinsburg Institute (Addiction Client Centered Treatment) 304-263-1101 http://www.addictiontreatmentsystems .com/martinsburg-institute
Live Well West Virginia http://well.wvu.edu/wellness/livewell
Shenandoah Community Health Center 304-263-4999 www.svms.net
Give them the number for Eastern Panhandle Transit Authority (PANTRAN). Call 211 for assistance
Suggest that they call DHHR to see if they qualify for free passes for PANTRAN.

In the last 12 months, have you ever had to go without What to hand them:
healthcare because you didn’t have a way to get 211 Pocket brochure – highlight with marker the transportation options
there?
Resource list - highlight with marker the transportation options

Free PANTRAN passes if available from Social Workers/Family Community Outreach Coordinator.
This question provides knowledge for Social Workers/Family Community Outreach Coordinator to help them read information
provided by school or community. Call 211 for assistance

Berkeley County Adult Learning Center 304-263-3897 http://berkabe.weebly.com

Direct them to call resources and see what they offer if they want to learn to read better. Horizon Goodwill Industries 304-267-3177 www.horizongoodwill.org
Do you ever need help reading information given to Learning Center for Adult Education at James Rumsey Technical Institute
you? 304-754-9712 www.jamesrumsey.com
What to hand them: Lifelong Learning Program at Shepherd University 304-876-5135 http://www.shepherd.edu/lifelonglearning
211 Pocket brochure – highlight with marker the literacy options Literacy Volunteers of the Eastern Panhandle 304-264-0298 www.lvep-wv.org
WorkForce West Virginia Career Center 304-267-0065 www.wvcommerce.org
Resource list - highlight with marker the literacy options
Question to ask: Call 211 for assistance
Are they afraid due to building concerns or abuse in their homes? Berkeley County Substance Abuse Prevention 304-703-9274
BOLD (Building Our Lives Drug Free) 304-886-1347
Are you afraid you might be hurt in your apartment If building concern: Advocate for them with building manager Community Alternatives to Violence 304-262-4424 www.commav.org
building or house? If fear of abuse: Be certain they have the information for the Community Empowerment Center Potomac Highlands Guild, Inc. 304-596-9323 www.thephg.org

Important:
Make sure they know to call 911 in case of emergency.
TMI Social Worker/Case
Manager
Date of Screening Social Determinants of Health
Questions
In the last 12 months, did you ever eat less than you
felt you should because there wasn’t enough money
for food?
In the last 12 months, has your utility company shut off
your service for not paying your bills?
Are you worried that in the next 2 months you might
not have housing?
Do problems getting child-care make it difficult for you
to work or study?
(leave blank if you do not have children)
In the last 12 months, have you needed to see a
doctor, but could not because of the cost?
In the last 12 months, have you ever had to go without
healthcare because you didn’t have a way to get
there?
Do you ever need help reading information given to
you?
Are you afraid you might be hurt in your apartment
building or house?
If Yes, Date of Warm Check-in with family: Did they receive
Handoff (within 3 months Warm Hand-off assistance they needed? (within 1
of screening) month of warm hand-off)
Questions to ask:
Have they been to a food bank already?
Which ones have they been to?
Do they want us to help them call?
Call with them?
What to hand them:
211 Pocket brochure – highlight with marker the food options
Resource list - highlight with marker the food options
Direct them to:
DHHR to Regional Resource Connection or Telamon - These provide low
income assistance for utility bills
Catholic Charities – will provide income assistance
Different churches in Martinsburg - Churches have funds that they
distribute to families in need.
What to hand them:
211 Pocket brochure – highlight with marker the utility assistance
options.
Resource list - highlight with marker the utility options
Considerations:
If the worry is that in the next two months they will not have housing,
refer to Telamon or Habitat to Humanity.
If the worry is immediate and urgent, then handoff to Alicia at Homeless
Coalition. SW/FCOC should call to Alicia at 304-579-5150.
What to hand them:
211 Pocket brochure – highlight with marker the housing options
Resource list - highlight with marker the housing options
With the family, contact DHHR to see if they are eligible for Mountain
Heart. Mountain Heart funds childcare cost.
What to hand them:
211 Pocket brochure – highlight with marker any child care options
Resource list - highlight with marker the childcare options
Questions to ask:
Do they have Medicare/Medicaid?
Do they qualify for Medicare/Medicaid?
Help them:
If they qualify for Medicare/Medicaid and haven’t applied, help them fill
out paperwork online.
Send them to Free Clinic – 601 S Raleigh Street, Martinsburg, WV.
Give them the number for Eastern Panhandle Transit Authority
(PANTRAN).
Suggest that they call DHHR to see if they qualify for free passes for
PANTRAN.
What to hand them:
211 Pocket brochure – highlight with marker the transportation options
Resource list - highlight with marker the transportation options
Free PANTRAN passes if available from Social Workers/Family
Community Outreach Coordinator.
This question provides knowledge for Social Workers/Family Community
Outreach Coordinator to help them read information provided by school
or community.
Direct them to call resources and see what they offer if they want to
learn to read better.
What to hand them:
211 Pocket brochure – highlight with marker the literacy options
Resource list - highlight with marker the literacy options
Question to ask:
Are they afraid due to building concerns or abuse in their homes?
If building concern: Advocate for them with building manager
If fear of abuse: Be certain they have the information for the
Community Empowerment Center
Important:
Make sure they know to call 911 in case of emergency.