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.

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.

Capital Region Health Connections
Albany, Rensselaer and Schenectady Counties

St. Mary’s Healthcare
Fulton & Montgomery Counties
Adirondack Health Institute

For more information regarding New York’s Health Homes, go to
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 link with the social services needed
• Makes sure all providers who are working with the member share information related to their care

Who can join a HEALTH HOME?

Persons who are receiving Medicaid and:
- have two or more chronic diseases (diabetes, asthma, heart disease, high blood pressure, and high BMI)
- or a Severe Mental Illness (SMI) 
- or HIV/AIDS 

Persons in need of assistance with referral and linkage to:
- medical treatment and care
- behavioral treatment and care 
- substance use treatment 

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 learning how to link and navigate the services available you. These services include: transportation; assistance with medications; assistance in 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.