Care Management
Health Home Care Management for Medicaid Beneficiaries
Circare Care Managers work with individuals to develop and maintain a person-centered comprehensive plan for accessing and using community services and supports necessary to promote well-being.
Health Home Care Management is a free program for Medicaid recipients
Circare Care Managers work with individuals to develop and maintain a person-centered comprehensive plan for accessing and using community services and supports necessary to promote well-being. These services and supports are provided through a network of organizations, with the care manager overseeing the process. The network includes not only healthcare providers but other social and community supports that are essential to a person’s overall health, such as housing and vocational services. The goal is to ensure access to appropriate services, improve health outcomes, reduce preventable hospitalizations and emergency room visits, promote the use of Health Information Technology (HIT), and avoid unnecessary care.
Please click here for more information about what a Health Home is.
Services Include
- Comprehensive care management
- Care coordination and health promotion
- Comprehensive transitional care from inpatient to other settings, including appropriate follow-up
- Individual and family support, which includes authorized representatives
- Referral(s) to community and social support services, if relevant
- The use of Health Information Technology (HIT) to link services, as feasible and appropriate
Eligibility Criteria
- Individual currently has active Medicaid; AND
- Individual meets the New York State Department of Health eligibility criteria of: two chronic conditions, or HIV/AIDS, or one or more serious mental illnesses; AND
- Individual has significant behavioral, medical, or social risk factors which can be addressed through care management.
Non-Medicaid recipients who have a Serious Mental Illness may qualify for services through our Non-Medicaid Care Management Program. Further information and referral instructions to the Non-Medicaid Care Management Program can be located here.
In addition, our Forensic Care Management program provides services to inmates with a psychiatric disorder who are transitioning into the community following incarceration. Further information and referrals to the Forensic Care Management Program can be located here.
Referral Process
Circare accepts referrals from the community including health care providers, community organizations, individuals and/or family members, through the Health Homes of Upstate New York. Learn More or send us an email below.
Hours of Operation
Services are provided both in the Circare office and in the community Monday through Friday from 8:30 AM to 5:00 PM.
On-Call services are available 24 / 7.
Non-Medicaid Care Management
For those who do not receive Medicaid, Care Management at Circare is available through our Non-Medicaid Care Management program. Circare Care Managers work with individuals to develop and maintain a person-centered comprehensive plan for accessing and using community services and supports necessary to promote well-being. These services and supports are provided through a network of organizations, with the care manager overseeing the process. The network includes not only healthcare providers but other social and community supports that are essential to a person’s overall health, such as housing and vocational services. The goal is to ensure access to appropriate services, improve health outcomes, reduce preventable hospitalizations and emergency room visits, promote the use of Health Information Technology (HIT) and avoid unnecessary care.
Services Include
- Comprehensive care management
- Care coordination and health promotion
- Comprehensive transitional care from inpatient to other settings, including appropriate follow-up
- Individual and family support, which includes authorized representatives
- Referral(s) to community and social support services, if relevant
- The use of Health Information Technology (HIT) to link services, as feasible and appropriate
Eligibility Criteria
Participants in the Non-Medicaid Care Management program must have a Serious Mental Illness. In order to be considered an adult with a serious and persistent mental illness, an individual must:
- Have a designated mental illness (meets criteria for a psychiatric diagnosis other than alcohol or drug disorders, organic brain syndrome(s), developmental disabilities or social conditions) AND
- Currently receive Social Security Income (SSI) or Social Security Disability Income (SSDI) due to a designated mental illness OR
- Demonstrate extended impairment in functioning due to mental illness OR
- Rely on Psychiatric Treatment, Rehabilitation and Supports
Referral Process
Referrals to this program are processed through Onondaga County’s Single Point of Access (SPOA) here or 315-435-7711, ext. 4695 or 4997. Contact SPOA or send us an email below.
Hours of Operation
Services are provided both in the Circare office and in the community Monday through Friday from 8:30 AM to 5:00 PM.
On-Call services are available 24 / 7.
Forensic Care Management
Forensic Care Management services are provided to individuals with a psychiatric disorder who are transitioning into the community following incarceration. Prior to discharge, Circare Forensic Care Managers collaborate with behavioral health and social services staff to assist with discharge planning. Following discharge, Forensic Care Management aims to reduce re-incarceration and assist individuals in connecting to services that support their wellness and recovery.
Forensic Care Management Services are...
designed to be shorter in term in order to allow the program to continuously enroll people as they are released from incarceration.
Eligibility Criteria
- Age 18 or older
- Onondaga County resident
- Pending discharge from incarceration or recent discharge (within 30 days) from incarceration
Hours of Operation
Services are provided both in the Circare office and in the community Monday through Friday from 8:30 AM to 5:00 PM.
