Community Healthcare Network


Health Home

A care coordination program

The Health Home Program is available to make sure its members get access to the care and services they need. We help our members learn about their health problems and connect them to care and resources in their communities. This helps them to have a better quality of life and more self-confidence.

About the Program

Under our Health Home you can get help with:

  • Linking to medical, mental health and substance use treatment in your community as needed
  • Signing up for entitlements like SSI and SNAP
  • Long Term Disability
  • Planning visits and transportation to visits if needed
  • Support for your health goals through care conferencing and advocacy with your doctors

What can a Care Manager offer to someone who joins the Health Home?

  • Talk to their doctor and help them know more about their care
  • Help with goal-setting and help them to reach their goals
  • Go with them to doctor’s visit and advocate on their behalf

To sign up for Health Home Services, you must:

  • Be 21 years of age or older
  • Have active and non-restricted Medicaid
  • Meet one of the following requirements: 2 chronic (lifelong) health problems (such as high blood pressure, diabetes, asthma, COPD, etc.) or Diagnosed with HIV or Diagnosed with a serious and lasting mental health condition have a need for care coordination

  • Health & Recovery Plan

    What is Health and Recovery Plan (HARP)?

    HARPs are specialized Medicaid Managed Care Plans. These plans are designed for people with more extensive or ongoing mental health and/or substance abuse conditions. HARPs have all the same services and benefits of “mainstream” Medicaid plans. These plans aim to help with recovery and wellness in the community through Home and Community Based Services (HCBS).

    What do Health and Recovery Plans do?

    • HARPs manage the Medicaid services for people who need them.
    • HARPs also manage an enhanced benefit package of Home and Community Based Services (HCBS)
    • HARPs offer enhanced care management for members to help them plan all their health needs, and non-Medicaid supportneeds.

    Who is eligible for HARP?

    • Must be 21 or older
    • Be insured only by Medicaid and be eligible for Medicaid managed care.
    • People who are eligible may get a letter in the mail from New York State or New York Medicaid Choice.

  • Adult Home Plus

    What is Adult Home Plus?

    Intensive Adult Home Plus care management offers specialized transitional care coordination services. With Adult Home Plus, the Care Managers:

    • Visit the member weekly
    • Connect members with supportive housing
    • Link them to health and mental health care in the community.

    Who is eligible for Adult Home Plus?

    • Must currently live in an impacted Adult Home defined by the settlement agreement
    • Must be diagnosed with a Serious Mental Illness
    • Must be signed up in a Health Home
    • Must want and be eligible to transition to the community under the terms and order of the settlement

  • Criminal Justice

    What is the Criminal Injustice initiative?

    To connect those who are Health Home eligible, being released from jail or prison or who have been in jail or prison before, to needed medical, mental health, substance use and/or other community support services. With the help of Correctional Health Services, for those being released from Rikers Island, their discharge planners will talk with them about the choice to sign up for the Health Home Program. If the person agrees, the discharge planner will work with our Criminal Justice Manager and connect them to a care management agency (CMA). The CMA will help them sign up for the Health Home program and access to the needed services and re-engagement into the community.

  • Why Refer to CHN

    Why Refer to CHN

    • High quality care coordination as recognized by New York State
    • Partnership with community based organizations in all five boroughs
    • Access to Federally Qualified Health Centers under our Health Home through our Care Management Agencies
    • Over 10 languages spoken at our agencies, with access to on staff interpreters and telephonic language lines.
    • In field provider education about the Health Home program, run by Health Home staff. Want to know more about the program and how it will help you and your patients? We’ll come to you

    Want to make a referral?

    Complete and send the CHN Health Home Referral Form via secure and confidential email or fax number below:

    Email: [email protected]
    Fax: 212-725-7766

  • Agencies we Refer to


    Our care management agencies have years of experience in care coordination. Many have been serving their communities for over 20 years. All have a wide range of resources to help and connect Health Home members to care they need. They service all five boroughs of New York City.

    Why Refer to CHN

    • Argus Community
    • Bailey House
    • Bridging Access to Care
    • Brightpoint Health
    • BOOM Health
    • CABS Home Care
    • CAMBA
    • Community Health Action of Staten
    • Island (CHASI)
    • Community Healthcare Network
    • Essen Healthcare
    • Federation of Organizations

    Want to make a referral?

    • Fortune Society
    • HeartShare St. Vincent’s
    • Housing Works
    • Mental Health Providers of
    • Western Queens
    • Metro CMA
    • National Association on Drug Abuse
    • Problems (NADAP)
    • OMH – Kingsboro Psychiatric Center
    • Puerto Rican Family Institute
    • The Bridge
    • Transitional Services for New York (TSINY)

    Want to make a referral?

    Complete and send the CHN Health Home Referral Form via secure and confidential email or fax number below:
    Email: [email protected]
    Fax: 212-725-7766

  • How can the Health Home help a potential member?

    We will:

    • Link members to medical, mental health and substance abuse services.
    • This includes:
      Help applying for entitlements like SSI and SNAP Referrals for emergency food resources, legal and educational support services and transportation
      Assistance with applying for home health aide Assistance and support with completing housing applications including supportive housing
    • Give a member visit reminders and go with them to their visits.
    • Help members with hospital discharge planning and stabilization after discharge.
    • Assess and assist with psychosocial needs.

    • Conference with member’s doctors and health care team to advocate on member’s behalf and to coordinate treatment planning as well is giving and receiving member progress updates.
    • Set up transportation to and from visits, if needed.
    • Help avoid emergency room visits.
    • Offer crisis intervention.
    • Educate members on how to navigate health and social services.

    Want to make a referral?

    Complete and send the CHN Health Home Referral Form via secure and confidential email or fax number below:
    Email: [email protected]
    Fax: 212-725-7766