Health Home Care Management Program

The Health Home Care Management Program serves adults experiencing homelessness or housing instability living with chronic physical and serious mental health conditions such as HIV/AIDS, diabetes, hypertension, bipolar disorder and anxiety disorders.

Clients must meet Health Home eligibility criteria, which generally include having two chronic conditions or one qualifying condition. The program prioritizes individuals with complex needs who benefit from coordinated care and ongoing support.

Care Managers work closely with clients to develop individualized care plans and coordinate services across healthcare and social service systems. 

Services include:

• Comprehensive care management and care coordination
• Health promotion and wellness planning
• Assistance navigating medical, behavioral health, and specialty care
• Coordination of transitional care following hospital or emergency room visits
• Referrals to community and social support services
• Support connecting to benefits, housing resources, and financial assistance
• Utilization of health information technology to support coordinated care

Care Managers serve as a consistent point of contact, helping clients access services, reduce unnecessary hospital visits, and improve overall well-being.

Participation in the Health Home Care Management Program improves access to coordinated healthcare and essential support. Clients benefit from clearer care pathways, reduced gaps in services, and support in managing complex medical and behavioral health needs.

By addressing health stability alongside housing and social needs, the program helps participants reduce crisis-driven care, improve quality of life, and strengthen their long-term stability.

Eligibility is verified using provider assessments, pharmacy data, PSYCKES reports, and other medical records. Referrals may come from healthcare providers, HSNY programs, street outreach teams, or community partners.

Established in 2018, MRT is a New York State Department of Health–approved Health Home. The program provides housing and care management services to Medicaid beneficiaries ages 18 and older who are experiencing homelessness, have been previously incarcerated, or are high utilizers of hospitals.

The program combines housing subsidies with coordinated care management to support long-term stability and reduce reliance on emergency systems.

The MRT program serves Medicaid recipients living with chronic medical conditions such as HIV/AIDS, diabetes, and hypertension, as well as individuals with serious mental health conditions. The program currently supports active clients and has successfully rehoused participants.

The integrated services that clients receive can include:

• Case management and care coordination
• Housing, education, and financial literacy
• Workforce training and employment support
• Mental health and substance use referrals
• Medical care linkages and ongoing support groups
• Crisis intervention and peer support

Through MRT, clients receive housing subsidies, care coordination, and individualized support that promote self-sufficiency and long-term housing stability. The program helps clients improve health outcomes, strengthen financial skills, and maintain stable housing.

Referrals are accepted from HSNY shelters, street outreach teams, and healthcare providers. Clients must complete an intake process and meet program eligibility criteria to receive housing and financial support.

Program outcomes are tracked through monthly and quarterly reporting to the New York State Department of Health, including housing status, client progress, and rental calculations.

Housing Solutions of New York partners with the Community Care Management Program (CCMP) to provide comprehensive, coordinated care for clients living with complex medical and behavioral health conditions. CCMP is a New York State Department of Health–approved Health Home made up of trusted partner organizations with a long history of serving individuals with chronic physical and mental health challenges.

Through this partnership, HSNY offers integrated, wraparound services that address both health and social needs. CCMP’s care management model ensures that clients receive consistent, person-centered support that promotes stability, improves health outcomes, and reduces reliance on emergency systems.

CCMP serves chronically ill New Yorkers, including individuals experiencing homelessness or housing instability, who require coordinated access to healthcare and social services. Clients often live with complex conditions that require ongoing care, navigation of multiple systems, and sustained support.

Through a comprehensive, community-based network, CCMP helps clients improve their health and well-being while promoting autonomy, dignity, and long-term stability.

The goal of CCMP is to improve health outcomes through high-quality care management that meets New York State Department of Health standards for Health Home implementation. Care Management Agencies like CCMP serve as the central point of coordination for patient-centered care and are accountable for improving outcomes and reducing avoidable healthcare utilization.

Services provided through the CCMP partnership include:

• Comprehensive care management
• Care coordination and health promotion
• Transitional care following inpatient stays, including timely follow-up
• Individual and family support, including coordination with authorized representatives
• Referrals to community-based and social support services
• Use of health information technology to support service coordination, where appropriate

This coordinated approach helps ensure continuity of care across medical, behavioral health, and social service systems.

Through the CCMP partnership, clients benefit from improved access to coordinated healthcare, reduced gaps in services, and stronger connections to community-based resources. The program helps prevent unnecessary hospital and emergency room visits while supporting wellness, preventative care, and post-discharge follow-up.

By addressing health needs alongside social and housing-related challenges, CCMP supports improved quality of life, greater stability, and more effective long-term care outcomes. This partnership strengthens HSNY’s ability to provide holistic support that treats the whole person, not just individual conditions.