Children’s Health Home Care Management is a care management service model whereby all an individual’s caregivers communicate with one another so that all of the patient’s needs are addressed in a comprehensive manner. This is done primarily through a “care manager” who oversees and provides access to all 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 among providers so that services are not duplicated or neglected. 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.”

Who is eligible to be in a Children’s Health Home?

Children from birth through age 21 enrolled in Medicaid and the child/youth meets the NYS DOH eligibility criteria of having one or more of the following:

  1. Two Chronic Conditions
  3. Serious Emotional Disturbance, or
  4. Complex Trauma

AND child/youth has significant behavioral, medical or social risk factors which can be addressed through care management.

What does a Children’s Health Home Care Manager do?

Coordinate with and for the client, and other providers involved to promote communication and collaboration of the care team; provide links and referrals to services for individual needs to assure individuals receive everything needed to stay healthy.

Goal setting, behavioral and educational needs, health promotion, transitional care, referrals to community and social supports and patient and family supports, and advocacy.

For more information please contact:

Kim Anglestein – Program Coordinator


Creating Hope, Transforming Lives