Health Home overview

At a glance

  • Over 160,000 members enrolled statewide, in 33 Health Homes in all 62 counties across New York State
  • Supported by a Coalition of Health Homes since 2015
  • Structure of Health Home lead agencies varies to meet community needs and includes:
    • Coalitions/consortia of community based providers (behavioral health, HIV, foster care), hospital led partnerships and Federally Qualified Health Centers.
  • Health Homes:
    • Serve individuals with the most challenging healthcare and social service needs, including those living with serious mental illness, many who are homeless, formerly incarcerated, individuals diagnosed with HIV/AIDS and individuals with 2 or more chronic medical conditions.
    • Partners have decades of experience providing services to these individuals and navigating community and formal healthcare resources.
  • Have been working with providers in every aspect of the health and social service delivery systems for years and have built extensive networks that allow them to provide integrated, coordinated care.

Health Home objectives

Health Homes improve outcomes for members through bi-directional communication with providers which results in:

  • Reduction of no-shows for appointments,
  • Increased engagement in treatment,
  • Support for members and their caregivers,
  • Member connections with culturally competent providers that understand and can meet their needs, and
  • Address underlying social determinants of health (such as housing, employment, and education).

Health Home care management improves the outcomes that the entire healthcare system is working toward, including:

  • Reduction of avoidable or preventable inpatient stays,
  • Reduction of avoidable emergency department visits,
  • Improved health outcomes for persons with mental illness and/or substance use disorders,
  • Improved management of disease-related care for chronic conditions including HIV,
  • Improved connectivity to preventive care and appropriate outpatient providers, and
  • Focus on social determinants of health such as homelessness, lack of food security and benefit connectivity.