Health Home Care
Management Program
Who We Serve
Serving homeless individuals and others with chronic health issues like Hypertension, HIV/AIDS, Diabetes, and mental health conditions such as Bipolar and Anxiety disorders. Participants need either two chronic diagnoses or a single qualifying condition.
How We Verify Eligibility
Eligibility is verified using provider assessments, pharmacy data, PSYCKES reports, and other medical records.
Our Services
Care Managers create personalized care plans, coordinate health services, and connect participants to essential resources to improve well-being.
Benefits of Participation
Participants receive improved care coordination, support navigating resources, and assistance connecting to services.
Medicaid Redesign Team (MRT) Health Home Supportive Housing Program
About the Program
Established in 2018, the MRT Program provides housing and case management services to Medicaid beneficiaries aged 18+ who are homeless, previously incarcerated, or high utilizers of hospitals. Participants must be Medicaid recipients and meet eligibility criteria under NYS Health Home programs.
Who We Serve
The program serves individuals with chronic conditions (e.g., HIV/AIDS, Diabetes, Hypertension) or serious mental health conditions. It currently supports 15 active participants and has helped rehouse multiple individuals.
Services Provided
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Case Management and Care Coordination
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Financial Literacy and Housing Education
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Workforce Training and Job Support
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Mental Health and Substance Abuse Referrals
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Medical Linkages and Monthly Support Groups
Benefits of Participation
Participants receive housing subsidies, peer support, crisis intervention, counseling, financial literacy training, and furniture allowances. The program helps individuals achieve self-sufficiency and long-term stability.
Referrals and Eligibility
Referrals come from HSNY shelters, street outreach, and healthcare providers. Participants must complete an intake process and meet program criteria to receive immediate housing and financial support.
Reporting and Accountability
Reports are submitted monthly and quarterly to the Department of Health, tracking participant progress, housing status, and rental calculations.
Community Care Management Partners
CCMP is a New York State Department of Health (NYSDOH) approved Health Home comprised of partners with a long history of service to those experiencing chronic mental and physical health challenges.
CCMP helps chronically ill New Yorkers navigate and access healthcare and social services to improve their health and wellbeing. Through our comprehensive community-based network, we offer person-centered, high-quality, and cost-effective care coordination services that promote stability, autonomy, and dignity.
The goal of CCMP is to improve the health of our members by providing quality care management. We pledge to promote the quality standards and best practices set forth by the NYSDOH with regard to health home implementation. Section 1945(h)(4) of the Social Security Act defines health home services as "comprehensive and timely high-quality services" and promulgates the following health home services be provided by designated care management agencies:
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Comprehensive care management
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Care coordination and health promotion
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Comprehensive transitional care from inpatient to other settings, including appropriate follow-up
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Individual and family support, which includes authorized representatives
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Referral to community and social support services, if relevant
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The use of health information technology (HIT) to link services, as feasible and appropriate
Our Care Management Agencies are the central points for coordinating and directing patient-centered care and are accountable for reducing avoidable health care costs, preventing unnecessary hospital and emergency room visits; providing timely post discharge follow-up, wellness and preventative care; improving member outcomes by addressing primary medical, specialist and behavioral health care; assisting the member in connecting with appropriate service providers, and promoting comprehensive and integrated support.
Contact Us
For Referrals: Jonte Taylor, Program Leader - Health Homes (CCMP and MRT)
j.taylor@hsofny.org