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Care Management

An individual’s support network includes not only the healthcare providers but other social and community supports that are essential to a person's overall health, such as housing and vocational services.

A Health Home is a service model designed to ensure effective coordination and management of care, leading to positive health outcomes for an individual, including reducing avoidable emergency department and hospital stays. A care manager works with the individual to develop and maintain a comprehensive plan for accessing services and supports necessary for the person's health. These services and supports are provided through a network of organizations, who collectively, become the person's virtual "Health Home" with the care manager overseeing the process.

Health Home Equality

Health Home services are provided to a subset of the Medicaid population with complex chronic health and/or behavioral health needs whose care is often fragmented, uncoordinated and duplicative.

Individuals served in a Health Home must have at least two chronic conditions; or one qualifying chronic condition and be at risk of developing another; or one serious mental illness. The chronic conditions described in Section 12945(h) (2) of the Social Security Act include, but are not limited to, the following:

  • Mental Health Condition
  • Substance Use Disorder
  • Asthma
  • Diabetes
  • Heart Disease
  • Overweight as evidences by BMI of 25
  • Other Chronic Condition
  • The Individual currently has active Medicaid; AND Individual resides in Seneca or Ontario County.


The Health Home service delivery model is designed to provide cost-effective services that facilitate access to a multidisciplinary array of medical care, behavioral health care and community-based social services and supports for individuals with chronic medical and/or behavioral health conditions.

Health Home services support the provision of coordinated, comprehensive medical and behavioral health services through care coordination and integration. The goal of theses core services is to ensure access to appropriate services, improve health outcomes, reduce preventable hospitalizations and emergency room visits, promote use of Health information Technology (HIT), and avoid unnecessary care.