Medicaid Health Home
What is the UHS Medicaid Health Home?
UHS Medicaid Health Home is a network of health care and community providers that are part of your “Care Team.” UHS Medicaid Health Home is dedicated to helping you spend less time in the hospital or emergency room and more time keeping you healthy and safe in the community.
What do Health Home Care Coordinators do?
UHS Health Home Care Coordinators will help you to access healthcare and connect you with services you need. Care Coordinators can help connect you to health care providers, mental health and substance abuse providers, social and community supports, housing and transportation services.
How can I start working with a Medicaid Health Home Care Coordinator?
If you have Medicaid and are eligible for Health Home services, a Care Coordinator will reach out to you or your family to schedule an appointment to discuss and develop a care plan to meet your individual needs, as well as additional services you may be eligible for.
Is a Health Home right for you?
You may qualify for Health Home services if:
- You are a Medicaid recipient over the age of 21
- You have 2 or more Chronic Conditions
- A Serious Mental Illness (SMI) OR HIV/AIDS
- Are in need of a Primary Care, Mental Health, or Substance Abuse Provider
- Have difficulty keeping medical appointments and struggle to obtain transportation
- Have been to the Emergency Department multiple times within the past 6-12 months
HARP & HCBS
A Health and Recovery Plan (HARP) is a managed care product that manages physical health, mental health, and substance use services in an integrated way for adults with significant behavioral health needs (mental health or substance use).
- Must be 21 or older
- Insured ONLY by Medicaid
- Enrolled in a Managed Medicaid Managed care
- Behavioral Health History
Benefits of HARP:
HARP Managed Care Organization (MCO) Care Managers are available to provide a person centered approach to member care in collaboration with the Care Team:
- Promote member health recovery
- Minimize gaps in care
- HARP’s will connect members with HCBS to provide a person centered approach to attain their recovery goals
- HCBS provides opportunities for members to receive services in their own home or community in order to decrease ER visits and inpatient admissions.
Home and Community Based Services (HCBS):
- Habilitation (Hab) –Helps members build their daily living skills
- Pyschosocial Rehabilitation (PSR)- Focus is on building socialization skills
- Community Psychiatric Support and Treatment (CPST) -Intent to get member connected to a Mental Health Provider
- Pre-Vocational Employment (PreVoc)- Prepares member to work
- Transitional Employment -Helps members gain work experience, like an internship
- Intensive Supportive Employment -Helps members obtain employment through job coaching and resume writing
- Ongoing Supported Employment -Helps members retain competitive employment
- Education Support Services (ESS)-Helps members obtain their GED in order become employed
- Peer Support Services -Staff lived through experience and mentor members for a more “real life” approach to achieving recovery goals
- Family Support and Training (FST)-Helps member’s families understand their MH and Substance Abuse
- Short-term Crisis Respite -Offers members a safe place when member wants to leave a stressful situation and peer support staff are available as well
- Intensive Crisis Respite-Helps members stay out of the hospital when they are having a crisis by providing a safe space and peer supports
HCBS Providers in Broome County:
- Catholic Charities
- Northeast Parent and Child Society
- The Star Group
- Mental Health Association of the Southern Tier (MHAST)
*Please note that not all HCBS Providers provide all of the HCBS services. For example The Star Group only provides employments services and Northeast only provides FST, PSR and CPST, HAB.Catholic Charities provides most of the HCBS services in Broome county at this time.
For more information, please contact:
UHS HARP/HCBS Specialist
Lead Health Home Team
Network and Administrative Manager
UHS Health Home Supervisor
HARP and HCBS Specialist
Billing and Compliance Specialist
Directory of Services, Physicians and Providers
Community Service Guide
Find a Health Home (By County)
Health Care Proxy
Care Management Agencies
Addiction Center of Broome County
Becka Moore, LMSW, CASAC
"We had a client with polysubstance abuse and serious mental health issues who could not stay clean and sober. The client was not able to identify a serious problem with use. The client had lost custody of her child a year prior to being connected to Health Home Services and was homeless. The client was set up with inpatient services and upon release was connected with all services with the help of ACBC Care Management Agency. Over a year later the client remains connected to outpatient services, has had her child returned to her custody, is stable in her housing, and is taking all of her medications as prescribed. The Client recently graduated from the health home program and continues to update us periodically."
Fairview Recovery Services, Inc
"We had a member become engaged with Fairview Recovery Services Health Home through a referral from Fairview’s Community Residence. The member struggled with memory deficits and lack of engagement to providers. After 2 years in the Health Home program and engagement with Fairview’s Supported Housing programs, the member is living in the community, employed, and preparing to successfully graduate from the Health Home program.“
The Family & Children’s Society, Inc.
“When we began working with one client, she was living in a women's shelter and suffering from a number of chronic conditions with no providers to treat her. Today, she is living independently in housing that is appropriate for her level of need, and is connected with a network of providers who are assisting her with effectively managing her wellness.”
Mental Health Association of the Southern Tier Inc.
Keith Leahey, MSW
“Prior to participating in the adult Health Home Care Coordination program with UHS and MHAST, the member was uncompliant due to the overwhelming amount of medications required on a daily basis. The member was visiting the Emergency Department on a monthly basis for over 6 months. Once enrolled into the adult Health Home program the member was provided with coordination of care to assist with a referral to a pharmacy that was able to enroll the member in a Blisterpak program. The Blisterpack program would sort and pack the medication and deliver them to the home on a weekly basis. The member is now compliant with all medications, which has reduced visits to the Emergency Department.”
Monroe Plan for Medical Care
“A member had been incarcerated, was homeless and was dealing with a lot of mental health issues. Our Care Manager was able to link the member to housing, community resources and providers to manage medical and mental health concerns. This member was able to get into treatment, receive medication and was eventually able to obtain and maintain a job. The member came back to see the Care Manager after discharge and told her that if it was not for this program and the assistance on learning to self-manage care he never would have made it to where he is in life today and would have taken a totally different path.”
Southern Tier Care Coordination
“Southern Tier Care Coordination has had many members who started out as clients and have flourished while working with our Care Managers. Many of those members have since gone on to become New York State Accredited Peers.“
United Health Services
“One of our members was battling M.S. and was really limited with mobility. As a care Manger I assisted in obtaining referrals to Neurology, PT and regular follow up appointments with the primary care doctor. The member also needed assistance in getting approval for a new transfusion to slow the process of M.S. This required a lot of phone calls to insurance and the neurology office. I was able to assist in getting transportation for a motorized wheelchair from A& D through Medicaid cab. The member is now using a walker in her home and walking a little bit each day from the benefits of her PT and infusions. The Member stated: "You know Care Management has helped me a lot. They have helped me get my medications and transportation that will transport motorized chairs. They even helped me get transportation to Syracuse to see a neurologist so that I could get a second opinion. Since then I have been receiving infusions for my M.S. I am now walking with a walker daily. I can't just sit in my wheelchair anymore, I want to walk! I AM WALKING!" The member thanks the supports of UHS Medicaid Health Home Care Management services.”
United Methodist Homes Complete Care
“Our client with multiple unmanaged chronic health conditions was residing alone in substandard housing and was on the verge of eviction due to cleanliness of the apartment. The client was fearful of break-ins and would use a pile of litter boxes so he would be alerted to a break in if the boxes fell over. Due to the unclean environment aide services would not enter the home to assist with the client’s needs. The client suffered from depression, was not attending appointments with providers, and had a lack of transportation with little access to food. Our Care Manager assisted the client with cleaning the apartment and set up the CASA evaluation so that aide services could begin. The Care Manager was able to connect the member with a Primary Care Provider, assist with setting up medical appointments and obtain transportation. The Care Manager was also able to deliver food from local pantries and advocate for the client during multiple Emergency Department visits with insurance. The client now attends scheduled appointments, has reduced Emergency Department visits, lives in a new apartment and has better control and understanding of his Mental Health and chronic conditions. The client maintains constant communication with the Care Manager due to the trust that was earned through this process.“
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