Central New York Health Home Network 

Care management services

Comprehensive Care Management

Comprehensive Care Management offers clients access to more timely and appropriate care based on a comprehensive assessment of medical, behavioral, rehabilitative and social needs.

Care Coordination & Health Promotion

Care Coordination is about working with treating clinicians to ensure that client services are provided and changes in treatment or medical conditions are addressed as needed.

Doctor Office

Comprehensive Transitional Care

Transitional Care is follow-up care. It can include working with hospitals and ERs to facilitate care prior to discharge into the community, as well as working in residential/rehabilitative settings, following up with Care Teams and assessing goals.

Child at the Doctor

Member & Family Support

Care Management facilitates collaboration between providers, clients, family and support members to establish a continuing plan of care, including referrals to additional support services based on client need.

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Referral and Community & Social Support Services

Care Management also identifies resources within the community and helps the client receive services as needed. This can be clinical and require a referral, or a non-clinical service such as housing, transportation, etc.

adult services

The Health Home provides Care Management services to Medicaid or Medicaid Managed Care eligible adults who meet the criteria for services. Our Care Managers are trained to consider all of your needs, not just the physical needs but the emotional needs as well. They make sure everyone involved in your care is working together and sharing information that is important in supporting your overall wellbeing. Our services can assist you in many ways, such as:

  • Transitioning from the hospital back to the community

  • Obtaining safe housing, legal assistance, food and other health and essential needs.

  • Getting involved in activities to improve your quality of life and keep you healthy;

  • Learning about social and other activities in the community;

  • Making sure everyone involved in your care understands the care plan, created with your help to meet your goals.

Children's Services

Health Home Care Managers and service providers work together to make sure your child gets the care and services they need to stay healthy at the right time in the right amounts. A dedicated Health Home Care Manager is assigned to the child and is responsible for coordinating all of their health services. Care Managers help the child and family understand their chronic conditions, manage their symptoms and ensure that all treatment team partners involved with the child are working together.