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NMDoH Screener

NMDoH Screenerkdiego22024-10-09T15:23:16+00:00

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Congratulations on the upcoming addition to your family!  We are very excited to support you as you enter this new part of your life.

As part of this program, we will send you 2-3 care communications/week via text during your pregnancy. This program does not replace your doctor’s care; rather, it is intended as a helping hand.

To make sure we send information that will be most helpful to you, we’d like to get to know you better.

By completing this five-minute survey, you help Driscoll Health Plan understand your healthcare needs better. Your answers will help allow us to improve our services and make sure you get the care and support you need. Your input is very important in helping us serve you!

Some of the information from this survey will be used by Driscoll Health Plan to find areas where more help is needed and to recommend the right resources. This information may also be shared with HHSC and will be added to your Member Record.
Name:*
First Last
Member ID:*
Mobile number:*
What is your birth date?*
MM slash DD slash YYYY
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Client, please carefully review the following information before proceeding:
Informed Consent*
- 1) Participation in this screening is voluntary and will not affect your status as a Member of the Driscoll Health Plan.
- 2) The purpose of this screening is to find opportunities for Driscoll Health Plan to provide you with additional resources that may positively impact your health, safety, and overall well-being. The data collected will be based on questions related to non-medical topics in life that may impact your health.
- 3) The data collected in this screening will be used by Driscoll Health Plan to identify areas of need and in determining appropriate resources for referral. Data collected may also be shared with the Health and Human Services Commission (HHSC), and the screening will be a part of the Member Record.
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It looks like you haven't selected all the required consent boxes. To continue, please review and confirm your consent by selecting the first three options below.
Informed Consent*
- 1) Participation in this screening is voluntary and will not affect your status as a Member of the Driscoll Health Plan.
- 2) The purpose of this screening is to find opportunities for Driscoll Health Plan to provide you with additional resources that may positively impact your health, safety, and overall well-being. The data collected will be based on questions related to non-medical topics in life that may impact your health.
- 3) The data collected in this screening will be used by Driscoll Health Plan to identify areas of need and in determining appropriate resources for referral. Data collected may also be shared with the Health and Human Services Commission (HHSC), and the screening will be a part of the Member Record.
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- I wish to have my information remain within Driscoll Health Plan.

These questions are optional, but we encourage you to share as much information as you're comfortable with to help Driscoll Health Plan serve you better.
Food
Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.
Within the past 12 months, you worried that your food would run out before you got money to buy more.
- Often true
- Sometimes true
- Never true
- Decline to answer
Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.
- Often true
- Sometimes true
- Never true
- Decline to answer
Would you like help with your food needs?
- Yes
- No
- Decline to answer
Transportation
Within the past 12 months, has lack of reliable transportation kept you from medical appointments or getting medications?
- Yes
- No
- Decline to answer
Within the past 12 months, has a lack of reliable transportation kept you from doing things you need to do, such as grocery shopping or getting to work or school?
- Yes
- No
- Decline to answer
Would you like help with transportation?
- Yes
- No
- Decline to answer
Housing
What is your living situation today?
- I have a steady place to live.
- I have a steady place to live today, but I’m worried about losing it in the future.
- I don’t have a steady place to live. I am temporarily staying in another person’s home, in a hotel, shelter, car, abandoned building, bus or train station, or living outside on the street, in the woods, or in a park.
- Decline to answer
Think about where you live when answering the next six questions.
Do you have problems paying for utilities, such as electricity, gas, heat, air conditioning, or water?
- Yes
- No
- Decline to answer
Do you have problems with utilities not working, such as electricity, gas, heat, air conditions, or water?
- Yes
- No
- Decline to answer
Do you have problems with pests like bugs or mice?
- Yes
- No
- Decline to answer
Do you have problems with mold?
- Yes
- No
- Decline to answer
Do you have problems with lead paint or pipes?
- Yes
- No
- Decline to answer
Do you have problems with smoke or carbon monoxide detectors missing or not working?
- Yes
- No
- Decline to answer
Would you like help with your living situation?
- Yes
- No
- Decline to answer
Child Care
Are you currently pregnant?
- Yes
- No
- Decline to answer
In the next 12 months, will you need help finding or paying for child care?
- Yes
- No
- Decline to answer
Would you like help with child care?
- Yes
- No
- Decline to answer
Next are some questions that are more sensitive in nature and may not apply to you. In no way are these questions intended to be judgmental. We want to ensure that we do our best to assess you for all your needs, so we best know how to assist you.
Safety
Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.
How often does anyone, including family and friends, physically hurt you or threaten to harm you?
- Never
- Rarely
- Sometimes
- Fairly often
- Frequently
How often does anyone, including family and friends talk down to, scream, or curse at you?
- Never
- Rarely
- Sometimes
- Fairly often
- Frequently
How often do you find that you are concerned or worried about your financial resources covering your household expenses over the past 3 months?
- Never
- Once or twice but not monthly
- Monthly
- Weekly
- Daily
Are you interested in information or applying for any of the following programs that can assist with meeting household and medical expenses?
(Select all that apply)
- Social Security Income (Disability) Benefits
- Medical or Intellectual Disability Medicaid Waiver Programs
- State Health Services Programs (SNAP, WIC)
Employment
Do you want help finding or keeping work or a job?
- Yes, help finding work
- Yes, help keeping work
- I do not need or want help
Mental Health
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
- Not at all
- Several days
- More than half the days
- Nearly every day
Feeling down, depressed, or hopeless?
- Not at all
- Several days
- More than half the days
- Nearly every day
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Stress
Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time.
Do you feel the kind of stress just described these days?
- Not at all
- A little bit
- Somewhat
- Quite a bit
- Very much
Community Resource Referrals
After completion of the NMDoH assessment, do you wish to be contacted by Driscoll Health Plan staff to continue with the initiation of community referrals for identified needs?
- Yes
- No
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Learn more about Services provided by Driscoll here:
https://driscollhealthplan.com/get-ready-for-baby/
https://driscollhealthplan.com/programs/star/value-added-services/
https://driscollhealthplan.com/programs/chip/value-added-services/

Driscoll Nurse Lines:
Nueces Service Area* – 833-532-0221
Hidalgo Service Area** – 833-532-0231

For additional support throughout your pregnancy, we suggest you to visit Hear Her Texas: https://www.dshs.texas.gov/hear-her-texas

* Nueces Service Area includes these counties: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Kames, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria
** Hidalgo Service Area includes these counties: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata

This program is completely voluntary and you may opt out at any time by replying STOP. For assistance with the program, reply HELP. Message and data rates may apply depending on your mobile carrier plan.

Continued use of this site signifies your consent and agreement with these Terms and Conditions.

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