Health Home Partners

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

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.

Health Home Outreach & Enrollment Offices

If you are interested in enrolling in our Health Homes program, you can visit or call one of our two outreach and enrollment offices in Long Island.

Nassau

175 Fulton Avenue, Suite 510
Hempstead, NY 11550

1 (888) 980-8410
Hours: 8am-5:30pm, Monday to Friday

 

Suffolk

The Maxine S. Postal Health Center
1080 Sunrise Highway
Amityville, NY 11701

1 (888) 980-8410
Hours: 8:30am-4:30pm, Monday to Friday

Our Partners and Providers for our Adult Health Home Program

Hudson Valley:

Columbia

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

Dutchess

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

Greene

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

Orange

  • Access: Supports for Living
  • Cornerstone Family Healthcare
  • HONORehg
  • Hudson Valley Community Services
  • MHA Orange
  • Rehabilitation Support Services
  • Rockland Psychiatric Center
  • Rockland Psychiatric Center ACT Orange

Putnam

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

Rockland

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

Sullivan

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

Westchester

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

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

Long Island:

Nassau

  • Central Nassau Guidance
  • Economic Opportunity Council of Suffolk
  • Empowerment, Assistance and Caring Network (EAC Network)
  • Long Island Federally Qualified Health Center
  • Melillo
  • MHA Nassau
  • New Horizon Counseling Center
  • Options for Community Living
  • Pilgrim Psychiatric Center
  • SAIL

Suffolk

  • Association for Mental Health and Wellness
  • Economic Opportunity Council of Suffolk
  • Empowerment, Assistance and Caring Network (EAC Network)
  • Family Service League
  • Federation of Organizations
  • Hudson River HealthCare (HRHCare)
  • Options for Community Living
  • Pilgrim Psychiatric Center
  • SAIL
  • Sayville Project
  • Suffolk County Dept of Community Mental Hygiene
  • WellLife Network

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

Our Partners and Providers for our Children’s Health Home Program

Hudson Valley:

Columbia County

  • Access: Supports for Living (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • Columbia County Department of Human Services (Mental Health, HIV, Foster Care/Child Welfare)
  • St. Anne Institute (Voluntary Foster Care Agency)

Dutchess County

  • Access: Supports for Living (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • AFEC Services, LLC (Complex Medical Needs, Early Intervention)
  • MHA Dutchess (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Rehabilitation Support Services (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • St. Anne Institute (Voluntary Foster Care Agency)

Greene County

  • Access: Supports for Living (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • Greene County Mental Health Center (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • St. Anne Institute (Voluntary Foster Care Agency)

Orange County

  • Access: Supports for Living (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • AFEC Services, LLC (Complex Medical Needs, Early Intervention)
  • Cornerstone Family Medical Center (HIV. Substance Use, Complex Medical Needs)
  • Honorehg (Housing, Mental Health, Medical Health)
  • Rehabilitation Support Services (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Rockland Children’s Psychiatric Center (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • St. Anne Institute (Voluntary Foster Care Agency)

Putnam County

  • ACCESS Supports for Living (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • AFEC Services, LLC (Complex Medical Needs, Early Intervention)
  • Open Door Family Medical Center (HIV, Medical Health, Mental Health)
  • Putnam Family & Community Services (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • St. Anne Institute (Complex Medical Needs, Early Intervention)

Rockland County

  • Access: Supports for Living (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • AFEC Services, LLC (Complex Medical Needs, Early Intervention)
  • Mental Health Association of Rockland (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Rockland Children’s Psychiatric Center (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • St. Anne Institute (Complex Medical Needs, Early Intervention)

Sullivan County

  • Access: Supports for Living AFEC Services. LLC (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • Rehabilitation Support Services, Inc. (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Rockland Children’s Psychiatric Center (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • St. Anne Institute (Voluntary Foster Care Agency)
  • Sullivan County Dept. of Community Services (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)

Westchester County

  • Access: Supports for Living (Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health)
  • AFEC Services, LLC (Complex Medical Needs, Early Intervention)
  • Blythedale Children’s Hospital (Complex medical needs)
  • Hudson River HealthCare, Inc. (Medical Health, Early Intervention)
  • Mental Health Association of Westchester (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Open Door Family Medical Center (HIV, Medical Health, Mental Health)
  • St. Anne Institute (Voluntary Foster Care Agency)
  • The Guidance Center of Westchester (Child Welfare,Early Intervention, Trauma, Substance Use)
  • Westchester Jewish Community Services (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)

Long Island:

Nassau County

  • EAC Network (Juvenille Justice, Mental Health)
  • Family and Children’s Association (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Options for Community Living, Inc. (Housing, HIV/AIDS, Mental Health
  • St Mary’s Hospital For Children (Complex Medical Needs, Early Intervention)

Suffolk County

  • Angela’s House (Complex Medical Needs)
  • Association for Mental Health and Wellness (Trauma, Mental Health)
  • Family and Children’s Association (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Family Service League (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Options for Community Living (Housing, HIV/AIDS, Mental Health)
  • St. Mary’s Healthcare System (Complex Medical Needs, Early Intervention)
  • Suffolk County Dept. of Mental Health Hygiene (Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed)
  • Wellife (Mental Health, Trauma)
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