What is a Health Home?

Health Home is a service model designed to ensure effective coordination and management of care, leading to positive health outcomes for the individual, including minimizing preventable emergency department and hospital stays. Health Home services are provided to a subset of Medicaid beneficiaries with complex chronic health and/or behavioral health needs whose care is often fragmented, uncoordinated and duplicative. A care manager works with the individual to develop and maintain a comprehensive plan for accessing and using services and supports necessary for the person’s health. These services and supports are provided through a network of organizations, which collectively become the person’s virtual "Health Home" with the care manager overseeing the process. The network includes not only healthcare providers but other social and community supports essential to a person’s overall health.

Circare has been designated a “Lead Health Home” by the New York State Department of Health. As a Lead Health Home, Circare is responsible for managing a network of providers and the provision of care management services to eligible enrollees in nine Central New York counties: Broome, Onondaga, Oswego, Cayuga, Cortland, Chemung, Madison, Tompkins, and Tioga. Circare is one of four Lead Health Homes operating in partnership with the New York Care Coordination Program/ Health Homes of Upstate New York (HHUNY) to bring Health Home services to 23 counties in western and central New York. Circare is also designated a Care Management Agency, with a staff of care managers who provide core services to Health Home members.

Referral Process

Circare accepts referrals from the community including health care providers, community organizations, individuals and/or family members. Learn More.

History of Health Homes

In 2010, the Affordable Care Act outlined a new option for states to provide Medicaid services to individuals with chronic conditions—Health Homes. Section 1945 was added to the Social Security Act and defined Health Home services as "comprehensive and timely high quality services". The section also defined eligibility criteria and six services to be provided by designated Health Home providers.

  1. Comprehensive care management
  2. Care coordination and health promotion
  3. Comprehensive transitional care from inpatient to other settings, including appropriate follow-up
  4. Individual and family support, which includes authorized representatives
  5. Referral to community and social support services if relevant; and
  6. The use of Health Information Technology (HIT) to link services, as feasible and appropriate.

Currently, Health Homes can be found in 22 States including Alabama, California, Connecticut, Iowa, Maine, Maryland, Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Dakota, Tennessee, Vermont, Washington, West Virginia, and Wisconsin as well as the District of Columbia. In New York State, Health Home Implementation was a result of the Medicaid Redesign Team (MRT) established by Governor Cuomo in January 2011. New York State has a total of 40 Lead Health Homes with at least one per county. The Health Home structure is three-tiered:

  • Lead Health Home: Provides management and support to care management agencies
  • Health Home Care Management Agencies: Provide Health Home core services to Health Home members
  • Health Home Network of Providers: Hospitals, Private Practices, Outpatient Clinics, Specialists, Educational Services, Vocational Services, Housing Services, etc.

If you have questions regarding eligibility for health home services, joining our network as a provider, or our process for delivering care management services, please contact:

Johanna George
Health Home Network Coordinator