These services are provided for individuals with Medicaid who are living in the community and need help in negotiating different systems in order to better take control of their lives. The primary goal of these services is to help individuals successfully remain in the community while improving the overall quality of their lives. Care Coordination will help clients maintain their mental health and medical treatment with the goal of reducing hospitalizations and emergency services. Care managers will assist clients by coordinating services with mental health and medical providers, and linking clients to community resources to enhance the quality of their lives. For those individuals who do not have Medicaid or are not eligible for Medicaid, care management is provided for clients who are 18 years old, a resident of Suffolk County and who have a primary diagnosis of a major mental illness as described in the DSM. The target population is an individual diagnosed with a Severe Mental Illness (SMI) that significantly impairs his/her ability to function in the community without supports. The primary diagnosis cannot be a Substance Use Disorder, an organic disorder, or a developmental disability.
The APSOA offers a centralized, coordinated referral process, using a universal referral form which can be found at:
Health Home Care Management: Health Home Care Managers provide comprehensive, integrated medical and behavioral health care management to Medicaid-enrolled individuals with chronic conditions to ensure access to appropriate services, improve health outcomes, prevent hospitalizations and emergency room visits and avoid unnecessary care. HHCM services include health promotion; transitional care, including appropriate follow-up from inpatient to other settings; patient and family support; and referral to community and social support services.
Health Home Non-Medicaid (State-Funded) Care Management: This program code applies to former Targeted Case Management programs, for both adults and children that converted to Health Home Care Management (HHCM). These funds are available to the HHCM provider who in addition to serving adult Medicaid enrolled recipients with a Serious Mental Illness (SMI) and children with Serious Emotional Disturbance (SED) also serves adult non-Medicaid SMI clients and children Non-Medicaid SED clients who cannot be enrolled in a Health Home. These funds typically support the higher acuity non-Medicaid recipients by advocating for needed services, helping to find their way through complex health care and social services systems, providing support for improved community service linkages, performing on-site crisis intervention and skills teaching when other services are not available, and if the recipient is eligible, working to secure Medicaid benefits with the goal of subsequent Health Home enrollment.