Health Home Care Management

Coordinated Care for Complex Lives.

Health Home Care Management connects high-need Medicaid members to the full spectrum of medical, behavioral, and social services they need to live healthier, more stable lives. At Elm & Oak, we serve as the central point of contact—coordinating care across providers, settings, and systems to ensure no one falls through the cracks. Whether someone is managing multiple chronic conditions, facing housing insecurity, or coping with mental health needs, our team of care managers helps guide them forward with compassion, consistency, and a whole-person approach to health.

What Is a Health Home?

A Health Home is not a place, it’s a program. It’s a New York State initiative designed to provide comprehensive, community-based care management for Medicaid members with complex needs. Each member is assigned a dedicated care manager who connects them to:

Primary and specialty care

Mental health and addiction support services

Housing and food resources

Medication management

Family and caregiver support

Education and employment programs

This integrated model ensures that care is not only coordinated, but personalized and sustainable.

Who’s Eligible?

Individuals may qualify for Health Home services if they:

Are enrolled in Medicaid or dually eligible, and
Have two or more chronic health conditions, or
Have HIV/AIDS, or
Have a serious mental illness (SMI)

Eligibility is determined through a combination of diagnosis and care complexity. Referrals can be made by providers, family members, or the individuals themselves.

Our Health Home Partners

Elm & Oak coordinates Health Home services in partnership with these respected provider organizations:

Chautauqua County Department of Mental Hygiene Health Home / Health Homes of Upstate New York (HHUNY)
Best Self Behavioral Health / HHUNY
Children’s Health Home of Upstate New York
Circare / HHUNY
Community Health Connections
Greater Rochester Health Home Network / HHUNY
Huther Doyle / HHUNY