Health Home is not a place, it’s a coordinated approach to providing great care


A network of community-based Care Management Agencies that work with individuals with serious and complex physical health, mental health and substance use disorders to achieve better health outcomes and reduce costs.

Client needs prior to Health Home enrollment

  • No primary care practitioner (PCP)
  • No connection to specialty doctor or other practitioner
  • Poor compliance (missed appointments, etc.)
  • Using the Emergency Department for the wrong reasons
  • Repeated recent hospitalization for preventable conditions either medical or psychiatric
  • Recent release from incarceration
  • The patient’s needs cannot be effectively met by their current primary care provider
  • Homelessness


  • Care Coordination and collaboration among providers
  • Decreasing Emergency Room and inpatient use
  • Supporting access to health care services
  • Linkage with community resources to provide comprehensive care

After enrollment, individuals saw an increase in:

  • Visits to primary care
  • Medication compliance

Health Homes improve outcomes for members by coordinating healthcare and social services, which result in:

  • Increased engagement in treatment
  • Support for members and their caregivers
  • Address underlying social determinants of health such as housing and employment


GRHHN links patients who have complex chronic conditions to community and care support systems. GRHHN Care Managers link clients with community resources to address food and housing needs.

Individuals must meet these requirements:

  • Medicaid recipients (includes managed care and dual eligible – Medicaid and Medicare)
  • Those who may have:
    • Significant mental illness or serious emotional disturbance
    • Sickle Cell
    • complex trauma, if under 21
    • two or more chronic health conditions (i.e. asthma, diabetes, heart disease, mental health condition, substance use disorder, etc.
    • HIV/AIDS
  • Those who have a significant behavioral, medical, or social risk factors that require the intensive level of Care Management services provided by the Health Home Program


Reduction in inpatient care post enrollment, compared to the same period prior to enrolling in a Health Home


Savings in NY inpatient costs

Health Homes Achieve Savings
and Improve Quality*


Reduction in all-cause readmissions (a measure of readmission following acute inpatient stays)

*According to NY Health Home Coalition and NYS Care Management Coalition

Make an online care management referral or call 585-350-1400 if you have any questions.

Referrals can also be submitted to GRHHN via fax at 585-978-7714 or sent via secure email to
Patient consent is required (verbal consent is acceptable).