Care Coordination Services
Catholic Charities Care Coordination provides Medicaid intensive case management services for people with chronic conditions under the auspices of New York’s Health Home Initiative and in collaboration with area lead health home agencies.
The lead health home agencies, along with NYS Department of Health and Managed Care Organizations, identify individuals eligible for the program and then assign individuals a care coordinator. Catholic Charities Care Coordination Services employs Care Coordinators at each service site that work with individuals in the health homes. Our Care Coordinators, in turn, collaborate with the lead health homes in the counties.

Service Sites
HEALTH HOMES
What Is A Health Home?
A Health Home is a group of health and community agencies that have agreed to work together to help people with many serious and chronic health issues get what they need to keep them healthier and safer in their communities. Each health home member is matched with a care coordinator who works with the person to help them with all kinds of health issues as well as social and housing issues.
Lead HEALTH HOME Agencies

Bassett Community Health Navigation
Chenango, Delaware,
Otsego & Schoharie Counties
www.bassett.org
607.547.4887
Capital Region Health Connections
Albany & Rensselaer Counties
www.sphcs.org
518.271.3301
Care Central
Schenectady & Saratoga Countie
www.carecentral.org
1.855.204.0888
Hudson River Health
Care Health Home
Columbia & Greene Counties
www.hrhcare.org
1.888.980.8410
St. Mary’s Healthcare
Fulton & Montgomery Counties
www.smha.org
518.841.3896

For more information regarding New York’s Health Homes, go to www.health.ny.gov
What does a HEALTH HOME help members do?

• Pay special attention to health care needs
• Makes sure members get the medical services and medications needed
• Helps members get the social services needed, such as housing and food
• Makes sure all providers who are working with the member share information related to his/her care

Who can join a HEALTH HOME?

Persons who are eligible for Medicaid and have HIV/AIDS, a chronic mental illness or two chronic diseases (diabetes, asthma, heart disease, high blood pressure, substance abuse or are very overweight) may be able to join.

How does HEALTH HOME work?

If you are enrolled in a Health Home, a care coordinator will work with you to make a care plan to address your needs. This can include help with: getting housing or food; arranging transportation; getting your medications and assistance with taking them; and scheduling and keeping appointments. A Care Coordinator will work with you and the Health Home team to help you get the services you need and to teach you how to stay healthy. This will help you avoid crises and the need to go to the emergency room or the hospital.