St. Mary's Healthcare is a New York State-designated lead Health Home and serves all ages. 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.

Our Role

We coordinate medical and behavioral health care for adults and children by connecting community and social supports with health care for high-risk Medicaid members with:

• HIV/AIDS; or
• a serious persistent mental illness; or
• two or more other chronic conditions.

Additionally, any of the following risk factors must be a part of the person’s situation. These reasons include, but are not limited to:

• Homelessness or risk of homelessness;
• Lack of or inadequate social/family housing support;
• Deficits in activities of daily living, learning or cognitive issues;
• Non-adherence to treatments;

Goal

The St. Mary's Health Home Care Coordination program's goal is to improve care coordination for high-risk Medicaid individuals, reduce duplicative services, reduce emergency department visits and inpatient admissions, and lower costs.

The St. Mary's Heath Home Care Coordination program is a partnership of primary care providers, hospitals, and several behavioral health and community-based organizations.

Contact Us

For more information about the St. Mary's Health Home Care Coordination program, call (518) 770-6875.