Health Home Care Management

Health Home Care Management Program

A Health Home is a care management service model whereby all of an individual’s caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner. This is done primarily through a Care Manager who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared (either electronically or paper) among providers so that services are not duplicated or neglected. The Health Home services are provided through a network of organizations – providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual “Health Home.”

Our Care Management Program is designed to assist individuals with various service coordination needs, goal setting, health promotion, transitional care, referrals to community & social supports, patient and family supports, and advocacy.

Common goal areas are stabilizing housing, financial management, medication management, finding and engaging with various types of supports, community integration, finding employment, furthering education, physical wellness.   These are just some of the goal areas individuals can choose from depending on their needs and situation.

Individuals work with a primary Care Manager to discuss their needs and create their own Plan of Care.  This Plan of Care is designed by the client and for the client, and will include other service providers, and supports in their life.  The individual will have responsibilities in the Plan, as will others, to help them accomplish their goals and meet their needs.  The Care Manager will, with permission, collaborate with other agencies and service providers to help meet the individual needs and coordinate services.

This is a voluntary program.  Common misconceptions – some people think Care Management is a long term/life long program.  This is not true.  Care Management is a short term (based on individual needs) program designed to assist individuals so that they can learn to manage their overall health and wellness, and be able to meet their needs on their own.  We help individuals work through crises, stabilize, and coordinate services so that supports are in place for continued wellness.  Care Management does not provide housing nor transportation.

Health Home Care Management Services Eligibility

  1. Individual currently has active Medicaid; AND;
  2. Individual meets the NYS DOH eligibility criteria of: two chronic physical health conditions, or HIV/AIDS and the risk of developing another chronic condition or, one or more serious mental illnesses; AND;
  3. Individual has significant behavioral, medical or social risk factors which can be addressed through care management.

Local Care Management:

Provides Care Management as described above to adults in Oswego County, diagnosed with a serious mental illness, and who do not have Medicaid.

Referrals for the Non-Medicaid Care Management Program are made through the Oswego County Single Point of Access (SPOA).

Catholic Charities of Oswego County
Health Home Care Management
808 W Broadway, Fulton, NY 13069

Creating Hope, Transforming Lives