Care Management

Abby Jeffrey, LCSW
Director, Health Homes

858 E. 29th Street,
Brooklyn, NY 11210

917-808-4800

For more information:

Kathleen Rivera, LCSW
Vice President,
Care Management Services

384 East 149th Street, Suite 504,
Bronx, NY 10455

Bronx: 347-293-4160
Brooklyn: 718-758-7838

Contact us

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Health Homes

 

What is a Health Home?

A Health Home is a program, not an actual place.
A Health Home is a new way of providing services to help make sure all of your health care needs are met. Your physical, behavioral health care needs will be coordinated by a dedicated care coordinator, who will work with you, all of your providers, and your support system—including your family.

 

Why would I need a Health Home?
How would it help me?

Currently, people receive medical services from one place and mental health or substance use treatment from another place. The different treatment providers do not typically communicate with one another. As a result, people can end up in the hospital or emergency room unnecessarily. Your dedicated care coordinator will work to improve your knowledge about your conditions/disease and your self-management capabilities and help you understand how “sticking to the plan” will increase your health and wellness and enhance the quality of your life. Your care coordinator can:

  • Coordinate services that meet your physical, mental health, chemical dependency and social service needs

  • Set up doctor’s appointments and review service plan to ensure you have what you need to stay healthy

  • Support you in following your treatment team’s recommendations

  • Provide health tips or strategies to manage conditions like diabetes, asthma, and high blood pressure and support lifestyle goals such as weight loss, healthy eating, exercise and quitting smoking.

  • Identify community-based resources

  • Support you in finding or applying for stable housing

  • Help you apply for benefits and make sure you continue to receive them

  • Provide you with follow up care if you are hospitalized, working with the hospital to ensure that you return safely back to the community and making sure you get follow up care, medications and recommended services after discharge.

  • Work with your trusted family or caregiver to help with the planning or delivering of your care. All communications with your family will be done in a way that they can understand.

 

FAQs

Who is eligible?

People receiving Medicaid benefits that have a diagnosis of a serious mental illness/serious emotional disturbance, or have been identified as having Complex Trauma, or are HIV+, or have two or more serious chronic medical conditions (including substance use disorder).

Will I need to get a new doctor? Or change to a different specialist? Or attend a new program?

You do not have to change doctors, specialists or groups to belong to a Health Home. Most people will be assigned to a Health Home that includes key treating providers or locations of treatment.

How do I join a Health Home?

You can talk to your treating provider (therapist, psychiatrist, primary care or clinic) about which Health Home they belong to or click here to find out which Health Home is closest to where you live or where you receive medical services: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_contacts.htm#nyc.

It is possible that New Yorkers on Medicaid, who meet the eligibility criteria for a Health Home have been identified by the State or Managed Care Company as likely to benefit from care coordination. In these cases, an outreach worker representing a Health Home will reach out to you to explain the benefits of the program and encourage signing up.

Additional Resources about Health Homes can be found at: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/

 

Health Homes Serving Adults & Children

  • Bronx Accountable Healthcare Network Health Home (BAHN)

  • County: Bronx

  • Community Care Management Partners (CCMP), LLC

  • Counties: Adults – Bronx, Manhattan; Children – All Five Boroughs

  • Coordinated Behavioral Care dba Pathways to Wellness

  • County: Adults – Brooklyn, Manhattan, Staten Island; Children – All Five Boroughs

  • St. Luke’s-Roosevelt Hospital Center dba Mount Sinai Health Home

  • County: Adults – Manhattan; Children – All Five Boroughs

  • North Shore – Long Island Jewish Health Home

  • Counties: Nassau, Queens, Suffolk

 

Health Homes Only Serving Children

  • Collaborative for Children and Families

  • Counties: All Five Boroughs, Westchester, Nassau, Suffolk

 

Health Homes Only Serving Adults

  • New York City Health and Hospitals Corporation

  • Counties: Bronx, Brooklyn, Manhattan, Queens

  • Bronx Lebanon Hospital Center

  • County: Bronx

  • Community Healthcare Network

  • Counties: Bronx, Brooklyn

  • Queens Coordinated Care Partners, LLC

  • Counties: Queens

  • Southwest Brooklyn Health Home, LLC dba Brooklyn Health Home

  • County: Brooklyn

  • The New York and Presbyterian Hospital

  • County: Manhattan

Abby Jeffrey, LCSW
Director, Health Homes

858 E. 29th Street,
Brooklyn, NY 11210

917-808-4800

For more information:

Kathleen Rivera, LCSW
Vice President,
Care Management Services

384 East 149th Street, Suite 504,
Bronx, NY 10455

Bronx: 347-293-4160
Brooklyn: 718-758-7838

Contact us