Finding the right healthcare can feel overwhelming, especially if you’re managing multiple health needs, navigating insurance, or trying to find LGBTQ+-affirming providers who understand your life experiences. That’s where the Health Home model comes in. A Health Home isn’t a place you live. It’s a care coordination program that brings together your medical, mental health, and social support needs under one team, so you don’t have to do it alone.
In New York City, Community Healthcare Network (CHN) offers a Health Home program designed to help patients access affordable, coordinated care that fits their real lives. Whether you need help with appointments, transportation, mental health services, housing support, or benefits like SNAP and SSI, your care team becomes your advocate and guide.
This guide explains what a Health Home Program is, who qualifies, and why it’s especially valuable for individuals managing chronic and mental health conditions, those impacted by the justice system, physical disabilities and those lacking consistent care and support, looking for accessible, holistic care.
Table of Contents
- Key Takeaways
- What Is a Health Home?
- Who Can Join a Health Home in NYC?
- How Health Home Care Coordination Works at CHN
- Why Health Homes Matter for LGBTQ+ New Yorkers
- CHN’s Health Home Programs and Partners
- What to Expect When You Enroll in a Health Home
- How a Health Home Helps With Everyday Barriers
- How to Get Connected to CHN’s Health Home
- FAQs: Health Home & Coordinated Care in NYC
Key Takeaways
- A Health Home is not a residence — it’s a Medicaid care coordination program that connects you to medical, mental health, substance use, and social services through a dedicated care team.
- CHN’s Health Home program helps members overcome everyday barriers, including housing challenges, transportation, benefits applications, and mental health support.
- LGBTQ+ New Yorkers benefit from affirming, trauma-informed care, with Care Managers, Patient Navigators, and Care Coordinators helping connect them to gender-affirming providers and culturally competent services.
- Specialized programs like Health and Recovery Plan (HARP) and the Criminal Justice initiative offer tailored support. This includes programs such as the NYC Health Justice Network and Transitions in Care components of our Criminal Justice programming, which supports individuals navigating the court system or with recent justice involvement, as well as those re-entering the community after incarceration.
- Enrollment is simple — you can be referred by a CHN provider, a hospital, a community agency, or correctional services, or inquire about joining directly at any CHN health center.
What Is a Health Home?
A Health Home is a New York State-approved care coordination program that connects you to the medical, mental health, and social services you need to stay healthy. It’s designed for people with chronic or ongoing conditions who benefit from having a dedicated team helping them navigate care.
A “Health Home” Is a Care Team – Not a Place You Live
Many people hear the term and think of a nursing home or residential facility. In reality, a Health Home is a network of support built around you.
Your Care Management team works with you, your doctors, and specialty providers to support your healthcare and social needs, ensuring nothing falls through the cracks.
A Care Management team can help you:
- Understand your health conditions
- Coordinate appointments and follow-ups
- Stay connected to mental health or substance use treatment
- Get support with benefits like SSI and SNAP
- Address social needs like food access, housing, or transportation
How Health Homes Support People With Complex Needs
Health Homes are especially helpful if you’re managing more than one condition or need extra support staying on track with care.
This model was created to:
- Reduce hospital and ER visits
- Improve long-term health outcomes
- Make affordable care easier to access
- Connect you with community-based services for stability and safety
CHN partners with Care Management Agencies across NYC, so support is accessible no matter where you live.
Who Can Join a Health Home in NYC?
Health Homes are designed for people who need extra support coordinating their medical, mental health, and social care. Eligibility is based on your health needs and Medicaid status — not income alone.
Basic Eligibility Requirements
You may qualify for a Health Home if you:
- Are 21 years of age or older
- Have active Medicaid
- Live in New York City
- Have two or more chronic health conditions, or
- Have a qualifying mental health diagnosis, such as schizophrenia or bipolar disorder, or
- Have a substance use disorder
Common qualifying conditions include:
- Diabetes
- Asthma
- HIV
- Depression or anxiety
- Substance use conditions
- High blood pressure
- Heart disease
Eligibility Examples for LGBTQ+ New Yorkers
Many LGBTQ+ people face unique barriers in healthcare — from past trauma to difficulty finding affirming providers. The Health Home model helps bridge these gaps.
LGBTQ+ New Yorkers often qualify if they are:
- Managing mental health conditions like depression, anxiety, PTSD, or bipolar disorder
- Living with HIV or other chronic medical conditions
- In need of help accessing stable housing
- Dealing with substance use–related concerns
- Facing challenges with continuity of care or insurance access
Even if you’re not sure whether you meet the criteria, CHN’s team can walk you through it confidentially.
How Health Home Care Coordination Works at CHN
At Community Healthcare Network, the Health Home program centers around a care team consisting of a Care Manager, Patient Navigator, and Care Coordinator, who together support your care. Your care team works together to:
- Talk with your provider to help you understand your treatment
- Attend medical appointments with you and advocate on your behalf
- Help you set achievable health goals and track progress
- Check in regularly to ensure your needs are being met
This team becomes your advocates and your guide through both the healthcare system and essential social support services.
Services Your Care Team Can Help With
CHN’s Health Home program covers a wide range of medical, behavioral health, and social services. Your care team can assist with:
- Connecting you to primary care, mental health, and substance use treatment
- Signing up for SSI, SNAP, Long-Term Disability, and other benefits
- Planning and scheduling medical visits
- Arranging transportation if needed
- Supporting your personal health goals
- Coordinating care conferences and team discussions
- Helping with housing applications, including supportive housing
- Offering crisis intervention when you need immediate help
- Providing reminders and follow-ups after hospital discharge
Specialized CHN Programs: HARP and Criminal Justice Support
CHN’s Health Home also includes two specialized programs for people with additional needs:
Health and Recovery Plan (HARP)
For adults with ongoing mental health and/or substance use conditions.
HARPs offer:
- Medicaid care management
- Home and Community Based Services (HCBS)
- Enhanced planning for medical and non-medical needs
Criminal Justice Initiative
The Criminal Justice Program includes two components:
- Health Justice Network (HJN): Supports individuals navigating the court system or with recent justice involvement (within up to three years).
- Quality Improvement Funds (Transitions in Care): Primarily supports individuals transitioning from Queensboro Correctional Facility and Edgecombe Residential Treatment Facility.
Support is provided by a Community Health Worker/Transition Support Specialist, who assists individuals with:
- Navigating healthcare systems post-release
- Connecting to medical, behavioral health, and social services
- Supporting reentry planning and stability
Why Health Homes Matter for LGBTQ+ New Yorkers
Many LGBTQ+ New Yorkers face barriers to consistent, affirming, and affordable healthcare — whether due to past discrimination, difficulty finding knowledgeable providers, or navigating complex life challenges like housing instability or mental health conditions. A Health Home helps bridge those gaps by offering coordinated, compassionate support.
LGBTQ+-Affirming, Trauma-Informed Care
CHN’s Health Home care managers, patient navigators, and care coordinators are trained to work respectfully with people of all identities and backgrounds. They help ensure you are connected to providers who:
- Use affirming language
- Understand LGBTQ+ health needs
- Create safe, nonjudgmental spaces
- Support gender-affirming care and mental health needs
This model is especially valuable for transgender and gender-nonconforming New Yorkers who often need coordinated support across multiple specialists.
Transgender Health Services
CHN’s Transgender Health Services (TGHS) program is dedicated to serving the transgender community across NYC. The program provides support to trans adults aged 21 and older with:
- Gender-affirming speciality services and surgeries
- Group education sessions about transgender care
Support Beyond the Exam Room
Healthcare doesn’t exist in a vacuum. Many LGBTQ+ individuals face higher rates of:
- Housing insecurity
- Food insecurity
- Unemployment or financial instability
- Social isolation
- Mental health conditions
Health Homes address both health and social needs, including:
- Connecting you to housing and supportive housing programs
- Helping you apply for SNAP, SSI, and disability benefits
- Linking you to legal, educational, and community resources
- Getting you transportation to your visits
- Providing reminders and ongoing support to stay on track
Real-Life Examples of Coordinated Support
Here are a few ways our care team might support an LGBTQ+ member:
- A transgender woman receives help scheduling hormone therapy appointments, applying for disability benefits, and finding supportive housing after a hospital discharge.
- A young gay man struggling with depression and substance use is connected to mental health counseling, community support groups, and reliable primary care.
- A nonbinary person who recently moved to NYC gets help navigating Medicaid, setting up medical appointments, and accessing food and emergency resources.
A Health Home meets you where you are and builds a plan that fits your life, identity, and long-term health goals.
CHN’s Health Home Programs and Partners
Community Healthcare Network works with a broad network of Care Management Agencies (CMAs) and specialized programs across New York City. This makes it easier for members to access the right care close to home, whether medical, mental health, or social support services.
Health and Recovery Plan (HARP)
HARPs are specialized Medicaid Managed Care Plans for adults living with ongoing mental health and/or substance use conditions. These plans include all the standard Medicaid benefits plus Home and Community Based Services (HCBS) to support long-term wellness and independence.
HARPs provide:
- Enhanced care management
- Help planning medical and non-medical needs
- Access to recovery-focused community programs
Criminal Justice Initiative: Re-Entry Support
People leaving jail or prison often lose connection to medical and mental health services — at the moment when they need stability most. CHN works with individuals transitioning from Queensboro Correctional Facility and Edgecombe Residential Treatment Facility, supporting their linkage to care upon release.
Our care team help with:
- Restarting medical care
- Accessing mental health and substance use services
- Getting benefits, housing referrals, and community support
- Re-engaging with healthcare after incarceration
Community Partners Across New York City
Community Healthcare Network works with long-standing community organizations that have been serving New Yorkers for decades. These Care Management Agencies provide deep local experience and culturally informed support.
Some of CHN’s partners include:
- Argus Community
- Bailey House
- Bridging Access to Care
- BOOM Health
- CAMBA
- Community Health Action of Staten Island
- Essen Healthcare
- Fortune Society
- HeartShare St. Vincent’s
- Housing Works
- NYC DOHMH Health Justice Network
- The Osborne Association
- Puerto Rican Family Institute
- Queensboro Correctional Facility
- Transitional Services for New York (TSINY)
This network ensures that members can receive high-quality care and support no matter where they live in NYC.
What to Expect When You Enroll in a Health Home
Joining a Health Home is simple — and once you’re enrolled, you get a dedicated team helping you navigate care, appointments, and everyday challenges. Here’s what the process typically looks like at CHN.
Step 1 – Referral and First Contact
You can be referred by:
- A CHN provider
- A hospital or clinic
- A community organization
- A correctional facility
- Or you can ask about enrolling yourself
Once a referral is made, a member of CHN’s Outreach Team may contact you by phone or in person to explain the program, answer any questions, confirm eligibility, and guide you through the enrollment process.
Step 2 – Creating Your Care Plan and Setting Goals
If you decide to join, you’ll meet with your care team to create a personalized care plan. This plan outlines your medical needs, mental health needs, social support needs, and long-term health goals.
Your care team will help you:
- Make a list of providers you see or need to see
- Identify barriers like transportation, housing, or insurance issues
- Prioritize your health goals (for example: managing diabetes, staying sober, or reducing stress)
- Build a plan that supports your identity, lived experience, and lifestyle
For LGBTQ+ members, this may include connecting you to affirming providers or gender-affirming care resources.
Step 3 – Ongoing Visits, Check-Ins, and Advocacy
Once your care plan is in place, your care team becomes your ongoing support system. They can:
- Check in regularly (phone, in-person, or community visits)
- Go with you to medical appointments and advocate for you
- Remind you of appointments and help reschedule when needed
- Coordinate with your doctors and specialists
- Assist with benefits applications and renewals
- Provide crisis support when something urgent comes up
- Help you stay stable after a hospital visit or ER visit
Your care team stays involved for as long as you need them — some people need support for a short time, while others benefit from long-term coordination.
How a Health Home Helps With Everyday Barriers
Health isn’t only about doctor visits — it’s shaped by your housing, transportation, food access, mental health support, and day-to-day stability. CHN’s Health Home model is built to help with all of those interconnected needs.
Getting to Appointments (Transportation & Reminders)
A major reason people miss medical care is simply not being able to get there. Your care team can:
- Arrange Medicaid-covered transportation
- Help plan travel routes
- Provide appointment reminders
- Assist with scheduling and rescheduling
This support makes it easier to stay consistent with treatment and follow-up care.
Housing, Benefits & Social Support
Health Homes address the social challenges that impact health the most. Your care team regularly helps you:
- Apply for SSI, SNAP, Long-Term Disability, and other entitlements
- Complete supportive housing applications
- Access emergency food, legal assistance, or educational resources
- Connect with home health aide services when needed
- Navigate benefits after leaving jail or prison
For LGBTQ+ New Yorkers, these services can reduce stress and improve safety, especially for those experiencing homelessness or family rejection.
Avoiding Emergency Room Visits & Getting Help in a Crisis
Our Health Home care team helps prevent unnecessary ER visits by keeping members connected to routine care. But they’re also there when a crisis happens.
They can:
- Coordinate crisis intervention
- Advocate for you during stressful or traumatic medical visits
- Help you stabilize after hospital discharge
- Ensure you have the follow-up care you need
This type of ongoing support makes a measurable difference in long-term health outcomes.
How to Get Connected to CHN’s Health Home
If you think a Health Home could help you, or someone you care about, CHN makes the enrollment process straightforward and confidential. You can get connected in several ways, depending on your situation.
Ask Your CHN Provider or Care Team
If you’re already receiving services at a CHN health center, simply ask your provider or a member of your care team about the Health Home program. They can submit a referral directly.
Referrals From Hospitals, Jails, and Community Agencies
Many people join through referrals from:
- NYC hospitals
- Mental health or substance use programs
- Community-based organizations
- Adult Homes
- Correctional Health Services
These partners help identify people who could benefit from coordinated care.
Where CHN Health Home Services Are Offered
CHN provides Health Home services at locations across New York City. Members can receive support through:
- CHN South Bronx Health Center
- CHN Long Island City Health Center
- CHN Jamaica Health Center
- CHN Washington Heights Health Center
- CHN Lower East Side Health Center
- CHN Crown Heights Health Center
Every site offers access to bilingual staff, interpretation services, and culturally informed care — including LGBTQ+-affirming providers.
Conclusion: Your Care, Your Team, Your Health Home
Managing your health shouldn’t feel overwhelming, and you shouldn’t have to navigate it alone. CHN’s Health Home program brings your medical, mental health, and social support needs together through a coordinated, team-based approach designed to support you every step of the way. Whether you are managing chronic or mental health conditions, navigating housing instability, benefits challenges, or transitioning back into the community after incarceration, our program is built to meet you where you are and help you move forward with stability and confidence. Your care team, whether it is a Care Manager, Patient Navigator, a Care Coordinator, a Community Health Worker or a Transition Support Specialist, works together to keep you connected, informed, and supported, so you can focus on your well-being rather than navigating complex systems on your own.
Through strong partnerships and a commitment to accessible, person-centered care, CHN’s Health Home program creates a pathway to consistent, holistic, and affordable care for all New Yorkers across Brooklyn, Bronx, Manhattan and Queens.
Get Connected to Coordinated Care Today
If you think the Health Home program could help you or someone you know, explore your options and start the referral process. Visit CHN’s Health Home page to get started.
Frequently Asked Questions
What is a Health Home in New York?
A Health Home is a Medicaid care coordination program that connects people with medical, mental health, substance use and other social support services through a dedicated care management team.
Does a Health Home cost money?
No. Health Home services are free for Medicaid members. There are no co-pays or additional fees.
Do I need a referral to join a Health Home?
You can be referred by a provider, hospital, community program, or correctional facility — or you can ask about enrolling yourself at a CHN health center.
Is the Health Home program LGBTQ+ friendly?
Yes. CHN’s Health Home is LGBTQ+-affirming and trauma-informed. The care team helps connect members to providers who respect and support their identity and health needs.
What conditions qualify someone for a Health Home?
Most members qualify through Medicaid if they also have two or more chronic conditions, a mental health diagnosis, or a substance use condition. CHN can help determine eligibility.
Can my care team attend appointments with me?
Yes. Someone in your care team can accompany you to visits, help you ask questions, and advocate on your behalf.