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Health Home Partners

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Community Health Care Collaborative

Hudson River HealthCare collaborates with the New York State Department of Health and partners with Care Management Agencies to keep you healthy!

What is a Health Home?

A Health Home is not a physical space. It is a group of health and community agencies that have agreed to work
together to help Medicaid members with serious and chronic health issues get additional support services and stay healthy & safe within their communities.

Each Health Home member will have a designated care manager to help them coordinate their care.

Who can join a Health Home?

Anyone who is eligible for Medicaid and has two chronic diseases such as diabetes, asthma, heart disease, high blood pressure, substance abuse or obesity, HIV/AIDS, or a chronic mental illness may be able to join.

As of December 2016 eligible candidates of all ages can receive Health Home Care Management services. Just like in our adult health home program, children are assigned to their own care coordinator and a personalized care plan is created driven by goals and preferences of the member and their caregiver. Potential members 18-21 can enroll in the adult or children’s programs.

What can my care manager help me with?

Care Manager

A care manager can help you stay healthy by assisting with:

  • Making and remembering appointments
  • Communicating between your doctors
  • Answering questions about your health care

A care manager can also help provide links to:

  • Housing, transportation & food
  • Health insurance
  • Medications
health home portal button

Refer a Patient

(For use by Primary Care Providers, MCO’s, CBO’s, Hospitals, Caregivers, friends, family…)

In order to refer a member for coordinated care management services please complete the appropriate referral form using the links below as well as patient consent and diagnostic information. Eligible patients will be directly contacted by CCC with information on their designated Care Coordinator, and a disposition report will be provided to the referring agency.

Please contact the Health Home Hotline at 1-888-980-8410 for any questions regarding eligibility or the referral process. Please be aware that the operator will prompt you to select the appropriate region you are calling for: 1 for Hudson Valley, 2 for Nassau County, or 3 for Suffolk County. For children under 18 choose the “Children’s Health Home” option.

You can complete an online referral form, which is preferred. Otherwise, you can complete a paper form (below) and fax to 914-606-3328. For the Children’s Health Home program, please utilize the Children’s Community Referral Form to make a referral.

Our Partners and Providers

Hudson Valley:

Westchester

  • Hudson River HealthCare (HRHCare)
  • Hudson Valley Community Services
  • Human Development Services of Westchester
  • Westchester Jewish Community Services
  • Rockland Psychiatric Center
  • Choice of New Rochelle
  • Phelps Memorial
  • MHA Westchester
  • St. Joseph’s Hospital
  • St. Vincent’s Hospital
  • St. John’s Riverside
  • MHA Westchester ACT
  • The Guidance Center of Westchester

Orange

  • Access: Supports for Living
  • Hudson Valley Community Services
  • MHA Orange
  • Rockland Psychiatric Center
  • Rockland Psychiatric Center ACT Orange
  • HONOREhg
  • Greater Hudson Valley Family Health
  • Rehabilitation Support Services

Dutchess

  • MHA Dutchess
  • Hudson Valley Community Services
  • Hudson River HealthCare (HRHCare)
  • Rockland Psychiatric Center ACT Dutchess

Sullivan

  • Hudson River HealthCare (HRHCare)
  • Rehabilitation Support Services
  • Hudson Valley Community Services
  • Sullivan County Department of Community Mental Health

Putnam

  • Putnam Family and Community Services
  • Hudson Valley Community Services
  • Rockland Psychiatric Center

Rockland

  • Hudson River HealthCare (HRHCare)
  • MHA Rockland
  • Jawonio
  • Hudson Valley Community Services

For more information, view the Hudson Valley Health Homes Brochure in English or Spanish.

Columbia and Greene Counties:

Columbia

  • Alliance for Positive Health
  • Catholic Charities
  • Columbia County Department of Human Services
  • Mental Health Association of Columbia & Greene
  • Greene County Mental Health

Greene

  • Alliance for Positive Health
  • Catholic Charities
  • Mental Health Association of Columbia & Greene
  • Greene County Mental Health

For more information, view the Columbia and Greene Counties Health Homes Brochure in English or Spanish.

Long Island:

Nassau

  • MHA Nassau
  • Melillo
  • Central Nassau Guidance
  • SAIL
  • The Jewish Board
  • Economic Opportunity Council of Suffolk
  • Empowerment, Assistance and Caring Network (EAC Network)
  • Pilgrim Psychiatric Center
  • Long Island Association for AIDs Care (LIAAC)
  • Options for Community Living
  • Long Island Federally Qualified Health Center

Suffolk

  • Hudson River HealthCare (HRHCare)
  • Sayville Project
  • Family Service League
  • Pedersan-Krag
  • Suffolk County Dept of Community Mental Hygeine
  • Outreach
  • Federation of Organizations
  • SAIL
  • The Jewish Board
  • Economic Opportunity Council of Suffolk
  • Empowerment, Assistance and Caring Network (EAC Network)
  • Pilgrim Psychiatric Center
  • Long Island Association for AIDs Care (LIAAC)
  • Options for Community Living
  • Association for Mental Health and Wellness

For more information, view the the Long Island Health Homes Brochure in English or Spanish.

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