When people in the Hudson Valley need help with food, housing, or utilities, many don’t start by searching for a program name or navigating a complex online form. They pick up the phone and dial 2-1-1.
That trusted first step is now playing a critical role in the success of the region’s Social Care Network (SCN), helping Medicaid members with health-related social needs gain vital access to services while strengthening the capacity of community-based providers like Feeding Westchester.
2-1-1 as a Trusted Front Door to the Social Care Network
Operated locally by United Way of Westchester and Putnam, the 2-1-1 call center serves as a central access point for residents across the Hudson Valley. Callers reach trained community resource specialists who listen first — allowing people to explain what they are facing before determining the best path forward.
That human-centered approach has proven especially effective for Social Care Network screenings.
Rather than directing people to an online self-screener, 2-1-1 specialists provide a human touch and identify Medicaid members during live calls and offer screening for health-related social needs when appropriate. In urgent situations, callers are immediately connected to emergency resources. When longer-term support is needed, 2-1-1 guides them through the SCN screening process and helps initiate referrals.
“It’s not scripted,” explains Lini Jacob, Chief Information and Referral Officer, 2-1-1 Hudson Valley, United Way of Westchester and Putnam. “We let callers share their story first. Then, if the need aligns with food, housing, or transportation support and they are on Medicaid, we walk them through what’s available and what the process looks like.”
Why This Matters for Medicaid Members
The human touch is an important workflow aspect. A phone call to 2-1-1 offers reassurance, clarity, and trust — especially for people navigating benefit changes, SNAP disruptions, rising utility costs, or housing instability.
Since becoming a partner in the Hudson Valley Social Care Network and activating the SCN option within its phone system, 2-1-1 has:
- Fielded over 7,000 calls related to food, housing, and utility assistance
- Identified Medicaid members eligible for SCN screening during real-time conversations
- Helped ensure callers receive immediate support while also opening the door to longer-term services
In moments of crisis, including the recent SNAP work requirement changes and benefit delays, 2-1-1 has played a stabilizing role, helping callers find alternatives and stay connected to local providers.
The Impact on Feeding Westchester and the Regional Food System
One of the clearest examples of this system working is Feeding Westchester, which has seen a meaningful increase in referrals through the Social Care Network.
Through the SCN, eligible Medicaid members can now receive weekly medically tailored food boxes, delivered directly to their homes. Each box provides a full week of shelf-stable, nutritious meals designed by a registered dietitian — supporting individuals with chronic conditions such as diabetes or heart disease.
For Feeding Westchester, this partnership has been transformational:
- The organization is currently serving over 130 individuals weekly, with capacity to scale quickly to 300 and beyond
- Deliveries are handled efficiently through DoorDash, allowing rapid expansion without new infrastructure
- Reimbursement through SCN is helping close critical funding gaps — with the program on track to help offset up to $1 million in lost government funding this fiscal year
Beyond finances, the operational benefits are significant. The SCN model has enabled Feeding Westchester to rethink how it reaches homebound seniors, Medicaid members, and individuals affected by sudden benefit disruptions — all while easing pressure on traditional food pantries during times of surging demand.
Related Story: Delivering a more effective approach to Westchester’s food insecurity
A Stronger Network, Working Together
What’s emerging is not just a referral pathway, but a coordinated ecosystem:
- 2-1-1 acts as a trusted entry point and navigator
- SCN provides the structure and funding to address health-related social needs
- Community partners like Feeding Westchester deliver services efficiently and at scale.
For Medicaid members, this means fewer barriers, faster connections, and support that reflects the realities of daily life. For providers, it means stronger collaboration, sustainable funding, and the ability to focus on what they do best.
As United Way leaders put it plainly: “We have the staff. We have the capacity. Send more calls our way.”
And as long as the Social Care Network remains in place, those calls are helping turn connection into care — one conversation at a time.
Click for more information on the Hudson Valley Social Care Network. And if you’re on Medicaid and struggling with daily living basics, like food, transportation and stable housing, dial 2-1-1 and get screened to see if you are eligible for extra support.
