Home Health Care
Management Program
Who We Serve
The Health Home Care Management Program serves adults experiencing homelessness or housing instability living with chronic physical and serious mental health conditions such as HIV/AIDS, diabetes, hypertension, bipolar disorder and anxiety disorders.
Clients must meet Health Home eligibility criteria, which generally include having two chronic conditions or one qualifying condition. The program prioritizes individuals with complex needs who benefit from coordinated care and ongoing support.
Services & Support
Care Managers work closely with clients to develop individualized care plans and coordinate services across healthcare and social service systems.
Services include:
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Comprehensive care management and care coordination
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Health promotion and wellness planning
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Assistance navigating medical, behavioral health, and specialty care
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Coordination of transitional care following hospital or emergency room visits
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Referrals to community and social support services
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Support connecting to benefits, housing resources, and financial assistance
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Utilization of health information technology to support coordinated care
Care Managers serve as a consistent point of contact, helping clients access services, reduce unnecessary hospital visits, and improve overall well-being.
Impact & Benefits
Participation in the Health Home Care Management Program improves access to coordinated healthcare and essential support. Clients benefit from clearer care pathways, reduced gaps in services, and support in managing complex medical and behavioral health needs.
By addressing health stability alongside housing and social needs, the program helps participants reduce crisis-driven care, improve quality of life, and strengthen their long-term stability.
Referrals & Eligibility
Eligibility is verified using provider assessments, pharmacy data, PSYCKES reports, and other medical records. Referrals may come from healthcare providers, HSNY programs, street outreach teams, or community partners.
One of our key partnerships supporting the program are....
Medicaid Redesign Team (MRT) Health Home Supportive Housing
Program Overview
Established in 2018, MRT is a New York State Department of Health–approved Health Home. The program provides housing and care management services to Medicaid beneficiaries ages 18 and older who are experiencing homelessness, have been previously incarcerated, or are high utilizers of hospitals.
The program combines housing subsidies with coordinated care management to support long-term stability and reduce reliance on emergency systems.
Who We Serve
The MRT program serves Medicaid recipients living with chronic medical conditions such as HIV/AIDS, diabetes, and hypertension, as well as individuals with serious mental health conditions. The program currently supports active clients and has successfully rehoused participants.
Services & Support
The integrated services that clients receive can include:
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Case management and care coordination
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Housing, education, and financial literacy
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Workforce training and employment support
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Mental health and substance use referrals
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Medical care linkages and ongoing support groups
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Crisis intervention and peer support
Impact & Benefits
Through MRT, clients receive housing subsidies, care coordination, and individualized support that promote self-sufficiency and long-term housing stability. The program helps clients improve health outcomes, strengthen financial skills, and maintain stable housing.
Referrals & Eligibility
Referrals are accepted from HSNY shelters, street outreach teams, and healthcare providers. Clients must complete an intake process and meet program eligibility criteria to receive housing and financial support.
Reporting & Accountability
Program outcomes are tracked through monthly and quarterly reporting to the New York State Department of Health, including housing status, client progress, and rental calculations.