Providing essential care management to those with chronic health conditions.

The Health Homes program provides essential care management services for children and adolescents ages 0-21 and adults ages 21+. Through personalized telephone and in-person meetings, our dedicated care managers meet clients where they feel most comfortable—at home, school, or within their community — with the goal of improving their overall well-being.

Health Homes involve a group of health care and service providers working together to help patients get the care and services needed to stay healthy. Our services are provided at no cost to Medicaid eligible individuals. We offer care coordination across physical health, mental health, and substance abuse providers, as needed. We also provide referrals for housing options and connection to other benefits and community programs.

We take a strength-based approach to care, recognizing each individual’s unique abilities while addressing their challenges. For children, we use the Child and Adolescent Needs and Strengths (CANS) Assessment to evaluate both the child and caregiver, ensuring our support is tailored to their needs and goals. For adults, we focus on removing barriers to healthcare by connecting them with Advanced Primary Care Practices (APCPs) and advocating for essential services.

At our core, we advocate for the overlooked and those without a voice, ensuring they receive the resources and support they need. Beyond medical and social services, we provide companionship and emotional support, recognizing that sometimes, just having someone to listen can make a profound difference. Our mission is to empower individuals, remove barriers to healthcare, and guide them toward a healthier, more fulfilling life.

Our program supports children from birth to age 21 who have at least two chronic health conditions or a serious emotional disturbance (SED). We also assist those who qualify with a single condition, such as HIV, sickle cell disease, or severe emotional disturbance. Additionally, we provide services for children with developmental disabilities like autism, as well as those managing conditions like severe asthma. To ensure each child receives the care they need, we offer four to five essential support services every month, helping families navigate their health challenges. We also serve adults aged 21 and older who are Medicaid recipients and living with chronic medical conditions, severe mental illness (SMI), HIV/AIDS, or sickle cell disease.

Many members of our community face barriers to healthcare, leaving them without access to critical resources. Our mission is to bridge that gap by providing guidance, education, and connections to services that enhance both medical and mental health outcomes for children and their families.

The Health Homes program plays a crucial role in reducing unnecessary emergency room visits by providing children and their caregivers with the support they need to manage their health effectively. We empower families by helping them understand their child’s diagnosis and connecting them to essential services that improve health outcomes.

Through referrals, we link children to behavioral health resources that help them manage their needs and prevent crises before they escalate. If a child requires OPWDD (Office for People With Developmental Disabilities) services, we facilitate referrals for psychological, psychosocial, and autism evaluations to ensure they meet eligibility requirements and receive appropriate care.