Introducing Health Home At-Risk

OneCity Health has launched the Health Home At-Risk project to expand access to care management services to patients who do not qualify for services under the New York State Department of Health (NYS DOH) Health Home program.

To understand the Health Home At-Risk project, it is important to first explain what a Health Home is: a Health Home is a care management service designed by the NYS DOH that focuses on the needs of patients with multiple chronic illnesses. In the Health Home program, all of an individual’s caregivers communicate with one another with the goal of addressing a patient’s medical and social needs in a comprehensive manner. You can read the NYS DOH Health Home requirements here.

In the Health Home, the work of identifying a patient’s medical and social needs and coordinating care is performed primarily by a Health Home Care Manager, a professional who oversees and organizes access to all of the services an individual needs to assure that they receive everything necessary to stay healthy within the community. If this service is provided effectively, New Yorkers will have less need to visit the Emergency Department and may be admitted less frequently to the hospital.

We know there are many patients who have significant medical and social care needs, and the Health Home At-Risk project will help us to meet New Yorkers’ needs by expanding access to care management services. In this project, these patients are initially known to have a single chronic disease and appear to have declining health and increasing health care needs.

We believe that professionals who work within the existing Health Home program have a good level of expertise and can also take care of the population of patients who need care management services, but do not qualify for the NYS DOH Health Home. Within the OneCity Health Performing Provider System (PPS), we have four Health Home lead agencies, and we recently shared a Project Participation Opportunity (PPO) with them in order to learn their interest in extending outreach and care management services to these patients. The full PPO can be read here.

In order to reach our goal of providing care management services to those who need it, but do not qualify for a Health Home, our initial steps will be to strengthen the link between primary care teams and those Health Home professionals who will now extend care management and coordination services to an expanded population of patients. We believe that this action is one of many that may be effective in helping to improve the identification – and addressing of – the social determinants of health.

OneCity Health partner organizations that are interested in providing care management and coordination services under this Health Home At-Risk project must be contracted with one of the four lead Health Homes within the PPS. They are:

  • NYC Health + Hospitals
  • Community Healthcare Network (CHN)
  • Community Care Management Partners (CCMP)
  • Coordinated Behavioral Care (CBC)

    OneCity Health partner organizations that provide Health Home care management services, but are not currently working with one of the four Health Home lead agencies, should contact one of the four Health Home lead agencies directly to initiate contracting. Contact information can be found here.

    Questions or concerns regarding this Project Participation Opportunity should be sent to with the subject line “Health Home At-Risk”.