Care Management

To enroll in the program, a Central New York Health Home Network (CNYHHN) community referral form must be completed and sent to CNYHHN: CNYHHN Adult Health Home Referral Form. You can make a referral for yourself or a family member. Individuals must meet all eligibility requirements to be considered for enrollment.

Eligibility requirements for the Adult Health Home Program are as follows:

• Must have active Medicaid or Managed Care, AND,
• Reside in Jefferson, Lewis or St. Lawrence County, AND,
• Meet the NYS Department of Health eligibility criteria:
  • Two or more chronic medical or mental health conditions (list of chronic conditions provided here NYS DOH Chronic Conditions; examples include asthma, diabetes, heart disease, obesity, etc.), or
  • HIV/AIDS or
  • Sickle Cell Disease
  • One or more Serious Mental Illnesses (SMI), AND
• Have significant behavioral, medical, or social risk factors which can be addressed through care management.

If you are interested in learning more about the Adult Health Home Program through CNYHHN, please visit: CNYHHN Health Home Network

Non-Medicaid Case Management is offered in Jefferson and Lewis Counties. It is a person-centered program designed to assist eligible individuals with needed case management services in order to be healthy. Once an individual’s eligibility is verified, they will be assigned to a Non-Medicaid Case Manager. The Case Manager will meet with the member to determine their needs and what is important to them. Together, the individual and case manager will develop an individualized service plan which addresses barriers in achieving established goals. This process is driven by the individual and supported by the case manager.

Our Adult Non-Medicaid Case Management services can assist you in many ways, such as: transitioning from the hospital back to the community; obtaining safe housing, legal assistance, food and other health and essential needs; getting involved in activities to improve your quality of life and keep you healthy; learning about social and other activities in the community; making sure everyone involved in your care understands your care plan; helping you access specialty care or necessary medications; coordinating referrals; helping you manage your insurance benefits, etc.

To enroll in the program, a Single Point of Access for Adults (A-SPOA) application must be completed and sent to the SPOA Coordinator in your county. You can make a referral for yourself or a family member. Individuals must meet all eligibility requirements to be considered for enrollment.

Jefferson County A-SPOA Referral Form and Coordinator Information can be found here: Jefferson County A-SPOA Referral Form and Coordinator Information

Lewis County A-SPOA Referral Form and Coordinator Information can be found here: Lewis County A-SPOA Referral Form and Coordinator Information

St. Lawrence County A-SPOA Referral Form and Coordinator Information can be found here: St. Lawrence County A-SPOA Referral Form and Coordinator Information

Eligibility requirements for the Non-Medicaid Case Management Program are as follows:

• Must have one or more Serious Mental Illnesses (SMI)
• Cannot be eligible for Health Home Care Management Services (i.e., actively enrolled in Medicaid or Medicaid Managed Care)
• Have significant behavioral, medical, or social risk factors which can be addressed through care management.

• Must have one or more Serious Mental Illnesses (SMI)
• Cannot be eligible for Health Home Care Management Services (i.e., actively enrolled in Medicaid or Medicaid Managed Care)

The Lewis County C-SPOA Referral Form and SPOA Coordinator Information can be found here: Childrens Single Point of Access Application Part 1 (lewiscountyny.gov)

The St. Lawrence County C-SPOA Referral Form and SPOA Coordinator Information can be found here: SPOA For Children and Youth | St. Lawrence County (stlawco.gov)

For more information, please contact (315) 755-6538 or (315) 755-6528.

As a downstream provider of the Central New York Health Home Network (CNYHHN) and the Children’s Health Home of Upstate New York (CHUNY), we provide Children’s Health Home Care Management services in Jefferson, Lewis, and St. Lawrence Counties. Health Home Care Managers and service providers work together to make sure your child gets the care and services they need to stay healthy. A dedicated Health Home Care Manager is assigned to the child and is responsible for coordinating all their health services. Care Managers help the child and family understand their chronic conditions, manage their symptoms, and ensure all treatment partners involved with the child are working together.

To enroll in the program, a Central New York Health Home Network (CNYHHN) and/or a Children’s Health Home of Upstate New York (CHUNY) community referral form must be completed and sent to CNYHHN and/or CHUNY:

CNYHHN Children’s Health Home Referral Form

CHUNY Children’s Health Home Referral Form

You can make a referral for yourself or a family member. Individuals must meet all eligibility required to be considered for enrollment.

Eligibility requirements for the Children’s Health Home Program are as follows:

1. Must have active Medicaid or Managed Care, AND,
2. Reside in one of the following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Onieda, St. Lawrence, Albany, Schenectady or Rensselaer
3. Meet the NYS Department of Health eligibility criteria:
   • Two or more chronic conditions (list of chronic conditions provided here NYS DOH Chronic Conditions; examples include asthma, diabetes, heart disease, obesity, etc.), or
   • One single qualifying chronic medical or mental health condition:
     • HIV/AIDS; or
     • Sickle Cell Disease; or
     • Serious Emotional Disturbance; or
     • Complex Trauma
4. Have significant behavioral, medical, or social risk factors which can be addressed through care management

If you are interested in learning more about the Children’s Health Home Program through CNYHHN or CHUNY, please contact (315) 755-6538 or (315) 755-6528.