Programs · Health
Home Health Care Management
Coordinated care for adults living with chronic physical and serious mental health conditions.
Who We Serve
The Health Home Care Management Program serves adults experiencing homelessness or housing instability who live with chronic physical and serious mental health conditions such as HIV/AIDS, diabetes, hypertension, bipolar disorder, and anxiety disorders.
Clients generally have two chronic conditions or one qualifying condition, with priority for individuals with complex needs who benefit from coordinated care and ongoing support.
Services and Support
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Comprehensive care management and care coordination
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Health promotion and wellness planning
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Navigation of medical, behavioral health, and specialty care
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Transitional care after hospital or emergency room visits
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Referrals to community and social support services
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Support connecting to benefits, housing resources, and financial assistance
MRT Health Home Supportive Housing
Established in 2018, the Medicaid Redesign Team (MRT) program combines housing subsidies with coordinated care management for Medicaid beneficiaries 18 and older who are experiencing homelessness, were previously incarcerated, or are high utilizers of hospitals.
HSNY also partners with the Community Care Management Program (CCMP), a New York State approved Health Home, to deliver integrated wraparound services that address both health and social needs.
Impact and Benefits
Care Managers act as a consistent point of contact, helping clients access services, reduce unnecessary hospital visits, and improve overall well-being. Addressing health stability alongside housing helps participants reduce crisis-driven care and strengthen long-term stability.
Referrals and eligibility
Eligibility is verified using provider assessments, pharmacy data, PSYCKES reports, and other medical records. Referrals come from healthcare providers, HSNY programs, street outreach teams, and community partners.
All Programs
Temporary Transitional Housing
Community Health Programs
C.R.E.A.T.E. Supportive Housing
Home Health Care Management
Youth Services Program
Emergency Housing Program
Financial Literacy
Workforce Readiness: JUST Health
Need support now?
Speak with our team about shelter, food, and case management. Available 24/7.