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Health Home Care Management

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

  • Medicaid recipient and must meet one of the following conditions:
    1. Serious mental illness
    2. Living with HIV/AIDS
    3. Two or more chronic conditions
  • Chronic conditions include, but are not limited to:
    1. Mental Health Condition
    2. Substance Use Disorder
    3. Asthma
    4. Diabetes
    5. Heart Disease
    6. Overweight / Obesity as evidenced by a BMI of 25

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

To apply for Health Home Care Management Services, complete the HHUNY Community Referral Application Form. Please note that all care management applications are processed by Health Homes of Upstate New York (HHUNY) and referred to Circare when applicable.

Send the completed Community Referral Application via secure e-mail, fax, or mail to:

HHUNY
Community Referral Specialist
New York Care Coordination Program
Health Homes of Upstate New York
1099 Jay Street, Bldg J
Rochester, NY 14611

E-mail: tmarchese(at)hhuny.org
Fax: 585-613-7670

To apply for Health Home Care Management Services, complete the HHUNY Community Referral Application Form. Download the English language Community Referral Application below.

Download English PDF Form >

To apply for Health Home Care Management Services, complete the HHUNY Community Referral Application Form. Download the Spanish language Community Referral Application below

Download Spanish PDF Form >

Assistance with completing a referral can be provided by a Circare enrollment specialist at our office during business hours (Monday through Friday 8:30 AM – 5:00 PM) or by telephone at 315-472-7363.

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.

Questions

Molly Stuttler-James
Adult Care Management Services Coordinator
315-472-7363 x 165