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Hudson River HealthCare collaborates with the New York State Department of Health and partners with Care Management Agencies to keep you healthy!
What is a Health Home?
A Health Home is not a physical space. It is a group of health and community agencies that have agreed to work
together to help Medicaid members with serious and chronic health issues get additional support services and stay healthy & safe within their communities.
Each Health Home member will have a designated care manager to help them coordinate their care.
Who can join a Health Home?
Anyone who is eligible for Medicaid and has two chronic diseases such as diabetes, asthma, heart disease, high blood pressure, substance abuse or obesity, HIV/AIDS, or a chronic mental illness may be able to join.
As of December 2016 eligible candidates of all ages can receive Health Home Care Management services. Just like in our adult health home program, children are assigned to their own care coordinator and a personalized care plan is created driven by goals and preferences of the member and their caregiver. Potential members 18-21 can enroll in the adult or children’s programs.
What can my care manager help me with?
A care manager can help you stay healthy by assisting with:
- Making and remembering appointments
- Communicating between your doctors
- Answering questions about your health care
A care manager can also help provide links to:
- Housing, transportation & food
- Health insurance
- Medications
Refer a Patient
(For use by Primary Care Providers, MCOs, CBOs, Hospitals, Caregivers, friends, family…)
In order to refer a member for coordinated care management services please complete the referral form using the link below. Eligible patients will be directly contacted by CCC with information on their designated Care Coordinator, and our regional teams will follow up directly with the referring agency.
Please contact the Health Home Hotline at 1-888-980-8410 for any questions regarding eligibility or the referral process. Please be aware that the operator will prompt you to select 1 for Hudson Valley, 2 for Patient Services in Long Island, 3 for Provider Services in Long Island, or 4 for our children’s program.
You can complete an online referral form, which is preferred. If completing the online referral form is not possible, you can complete a paper form (below) and fax to 914-606-3328 for Hudson Valley referrals, or 845-765-9383 for Long Island referrals..
Health Home Outreach & Enrollment Office
If you are interested in enrolling in our Health Home program, you can visit or call our outreach and enrollment office in Long Island.
The Maxine S. Postal Health Center
1080 Sunrise Highway
Amityville, NY 11701
1 (888) 980-8410
Hours: 8:30am-4:30pm, Monday through Friday
Our Care Management Agency partners for our Health Home programs serving adults and children:
Columbia
Access: Supports for Living (children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
Alliance for Positive Health (adults)
Catholic Charities (adults)
Columbia County Department of Human Services (adults and children)
Children’s specialties: Mental Health, HIV, Foster Care/Child Welfare
Mental Health Association of Columbia-Greene Counties (adults)
Dutchess
Access: Supports for Living (children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
AFEC Services, LLC (children)
Children’s specialties: Complex Medical Needs, Early Intervention
Hudson River HealthCare (adults)
Hudson Valley Community Services (adults)
Mental Health America of Dutchess (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Rehabilitation Support Services (children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Rockland Psychiatric Center – Dutchess ACT Team (adults)
Greene
Access: Supports for Living (children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
Alliance for Positive Health (adults)
Catholic Charities (adults)
Greene County Mental Health (adults)
Mental Health Association of Columbia-Greene Counties (adults)
Nassau
Central Nassau Guidance & Counseling Services (adults)
Economic Opportunity Council of Suffolk (adults)
EAC Network (adults and children)
Children’s specialties: Juvenile Justice, Mental Health
Family and Children’s Association (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Hudson River HealthCare (adults)
Long Island Federally Qualified Health Centers (adults)
Melillo Center (adults)
Mental Health Association of Nassau (adults)
New Horizon Counseling Center (adults)
Options for Community Living (adults and children)
Children’s specialties: Housing, HIV/AIDS, Mental Health
Pilgrim Psychiatric Center (adults)
South Shore Association for Independent Living (SAIL) (adults)
Orange
Access: Supports for Living (adults and children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
AFEC Services, LLC (children)
Children’s specialties: Complex Medical Needs, Early Intervention
Cornerstone Family Healthcare (adults and children)
Children’s specialties: HIV, Substance Use, Complex Medical Needs
HONORehg (adults and children)
Children’s specialties: Housing, Mental Health, Medical Health
Hudson Valley Community Services (adults)
Rehabilitation Support Services (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Rockland Children’s Psychiatric Center (children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Rockland Psychiatric Center (adults)
Rockland Psychiatric Center – Orange ACT Team (adults)
Putnam
Access: Supports for Living (adults and children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
AFEC Services, LLC (children)
Children’s specialties: Complex Medical Needs, Early Intervention
CoveCare Center (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Hudson Valley Community Services (adults)
Open Door Family Medical Center (children)
Children’s specialties: HIV, Medical Health, Mental Health
Rockland Psychiatric Center (adults)
Rockland
Access: Supports for Living (adults and children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
AFEC Services, LLC (children)
Children’s specialties: Complex Medical Needs, Early Intervention
Hudson River HealthCare (adults)
Hudson Valley Community Services (adults)
Jawonio (adults)
Mental Health Association of Rockland (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Refuah Health Center (adults)
Rockland Children’s Psychiatric Center (children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Rockland Psychiatric Center (adults)
Suffolk
Angela’s House (children)
Children’s specialties: Complex Medical Needs
Association for Mental Health and Wellness (adults and children)
Children’s specialties: Trauma, Mental Health
Economic Opportunity Council of Suffolk (adults)
EAC Network (adults)
Family and Children’s Association (children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Family Service League (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Federation of Organizations (adults)
Hudson River HealthCare (adults)
New Horizon Counseling Center (adults)
Options for Community Living (adults and children)
Children’s specialties: Housing, HIV/AIDS, Mental Health
Pilgrim Psychiatric Center (adults)
South Shore Association for Independent Living (SAIL) (adults)
Sayville Project (adults)
Suffolk County Department of Community Mental Hygiene (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
WellLife Network (adults and children)
Children’s specialties: Mental Health, Trauma
Sullivan
Access: Supports for Living (adults and children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
Hudson River HealthCare (adults)
Hudson Valley Community Services (adults)
Rehabilitation Support Services (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Rockland Children’s Psychiatric Center (children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Sullivan County Department of Community Mental Health (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Westchester
Access: Supports for Living (adults and children)
Children’s specialties: Voluntary Foster Care Agency, Early Intervention, Mental Health, Medical Health
AFEC Services, LLC (children)
Children’s specialties: Complex Medical Needs, Early Intervention
Blythedale Children’s Hospital (children)
Children’s specialties: Complex medical needs
Choice of New Rochelle (adults)
The Guidance Center of Westchester (adults and children)
Children’s specialties: Child Welfare, Early Intervention, Trauma, Substance Use
Hudson River HealthCare (adults)
Hudson Valley Community Services (adults)
Human Development Services of Westchester (adults)
Mental Health Association of Westchester (children and adults)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
Mental Health Association of Westchester – ACT Team (adults)
Open Door Family Medical Center (children)
Children’s specialties: HIV, Medical Health, Mental Health
Phelps Hospital (adults)
Rockland Psychiatric Center (adults)
St. Dominic’s Family Services (children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Mental Health
St. John’s Riverside Hospital (adults)
St. Vincent’s Hospital (adults)
Westchester Jewish Community Services (adults and children)
Children’s specialties: Former Office of Mental Health Targeted Care Management Program, Severely Emotional Disturbed
