Health Home Care Management

At St. Mary’s Healthcare, our Health Home Care Management program is designed to provide compassionate, coordinated care for individuals living with complex medical, behavioral health, or social needs. Through personalized support and a team-based approach, we help you achieve better health outcomes—right from the comfort of your home and community.

What Is Health Home Care Management?
Health Home Care Management is a Medicaid-funded care coordination program that connects eligible individuals with a dedicated Care Manager. Your Care Manager will work closely with you, your family, healthcare providers, and community resources to make sure all your medical, behavioral, and social service needs are met.

A Health Home is not a place; it is a care coordination service that connects community and social supports with health care, and provides better organization of medical and behavioral health care. A Health Home ensures all caregivers involved with a person talk to one another so they can focus on their client’s needs.

Who Is Eligible?
You may qualify for Health Home Care Management if you:

• Are enrolled in Medicaid
• Have two or more chronic conditions, or
• Have HIV/AIDS, or
• Have a serious mental illness (SMI)
• Sickle Cell Disease (Children or Adults)
• Serious Emotional Disturbance- SED (Children)
• Complex Trauma (Children)
• Are at risk for hospitalization, homelessness, or poor health outcomes without support

Our team can help determine your eligibility and walk you through the enrollment process.

What Services Are Provided?
Your Care Manager will:

• Develop a personalized care plan
• Schedule and coordinate doctor’s appointments, mental health care, or specialist visits
• Assist with medication management
• Connect you with housing resources, food assistance, transportation, and other community supports
• Provide ongoing advocacy and emotional support
• Monitor your progress and adjust care as your needs evolve

Why Choose St. Mary’s?
St. Mary’s Healthcare has a long-standing commitment to compassionate, patient-centered care. Our Health Home team includes experienced professionals who truly listen, understand your needs, and work alongside you to improve your quality of life.

Get Started Today.
If you or someone you love could benefit from Health Home Care Management, we’re here to help.

Send our team an email at healthhome@nysmha.org and we’ll be happy to assist you. You can also speak with your healthcare provider or caseworker about a referral.

Let St. Mary’s Healthcare walk with you toward a healthier, more supported future—because every person deserves the chance to thrive.

Referral Forms:
Adult Referral
Child Referral