Health Home Care Coordination

Health Home Care Coordination services are designed to assist persons 18 and older with a serious mental illness who live in Madison County and the surrounding areas in obtaining needed mental health, medical, social, psychological, educational, financial, vocational, and other services to maintain maximum level of independence and community functioning. All participants are diagnosed with a serious and persistent mental illness (SPMI), demonstrate significant functional impairments which impact their ability to function independently within the community, and need support to connect to and/or maintain their ongoing outpatient mental health services. Many of these individuals are enrolled in Medicaid, have high utilization of mental health services, and are at high risk for crisis or acute care that result in frequent emergency room and/or hospital visits. A major goal of the Health Home Care Coordination program is to reduce the frequency of these emergency visits among these individuals. The target population of this program includes homeless individuals, individuals with multiple disabilities, individuals with forensic involvement, or any individual with a serious mental illness whose community placement is at risk due to difficulty in adhering to needed outpatient mental health services.

Program History

Health Home Care Coordination services have been available within New York State since 1989. The program has been modified through the years with a supportive level of care added in 1994. Beginning in 2001, the program offered a more flexible blended model which supports a team approach to serving individuals. After becoming a case management provider, Liberty Resources converted the program to the Intensive/Supportive model in January 2001. In January 2002 the program was transitioned into the team or blended model. In 2013, the program became a designated Health Homes care provider and became known as Health Home Care Coordination.

Scope of Services

The Health Home Care Coordinator completes an assessment with each individual to identify areas of need, personal resources and supports, strengths, goals and objectives. This process is person-centered, resulting in an individualized plan for maintaining the client’s well-being and pursuing their stated goals and objectives. The Care Coordinator draws from community resources through linkages and referrals to assist the individual with the network of resources that will help maintain their community status and promote further growth to maximize functional independence. This level of care management begins to transition towards discharge as more stability is achieved in the individual’s life.