NYC Health Home Program (Care Management Agency)

CCN General Medicine offers a comprehensive range of medical specializations for both chronic and acute conditions. It participates in the Health Home Program management by NYC CMA (Care Management Agency). Health Home program run by CMS is one of the most complicated outreach programs designed to address mental health patients with 1 or more chronic conditions. The program is delivered by a lead community agency, namely ‘Lead Health Home’ and CMAs.

Program Accountability

To be part of the program, patient needs to be enrolled in Medicaid. CCN General is responsible for maintaining the eligibility. Patient assignment is dynamic and managed by CMS and Lead Health Home. Roster management is a big deal for CCN General as patients can be added and/or dropped without their knowledge. Also, physical acknowledgement of the patient is required on a quarterly basis. In order to get reimbursed for the services provided, CCN General needed a system that can record and report monthly assessments and outreach activities.

In order to manage this population and provide timely care coordination, CCN General, chose Equipo’s Care Coordination system. The goals of the system were many:

Equipo’s care management platform solved the needs by providing an integrated care delivery system. Now, CCN has replaced numerous spreadsheets with active roster management and monitoring of all care activities. The system’s key components include:

Outcome