Children's Home Health Care Management

Our Care Management Program is designed to assist individuals with various service coordination needs, goal setting, health promotion, transitional care, referrals to community & social supports, patient and family supports, and advocacy.



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Comprehensive Home Health Care Services

A Health Home is a care management service model whereby all of an individual’s caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner. This is done primarily through a Care Manager who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital.


Health records are shared (either electronically or paper) among providers so that services are not duplicated or neglected. The Health Home services are provided through a network of organizations – providers, health plans, and community-based organizations. When all the services are considered collectively they become a virtual “Health Home.”


Individuals work with a primary Care Manager to discuss their needs and create their own Plan of Care. This Plan of Care is designed by the client and for the client, and will include other service providers, and supports in their life. The individual will have responsibilities in the Plan, as will others, to help them accomplish their goals and meet their needs. The Care Manager will, with permission, collaborate with other agencies and service providers to help meet the individual needs and coordinate services.

Common Goal Areas:

Goal setting

Social Supports

Medication Management

Behavioral and educational needs

Advocacy

Health supports

Finding Support Communities

Referrals and Eligibility

  1. Individual currently has active Medicaid; AND;
  2. Individual meets the NYS DOH eligibility criteria of: two chronic physical health conditions, or HIV/AIDS, or Serious Emotional Disturbance (SED) or Complex Trauma; AND;
  3. Individual has significant behavioral, medical or social risk factors which can be addressed through care management.


Additional Information


  • This is a voluntary program. Common misconceptions – some people think Care Management is a long-term/life long program. This is not true. Care Management is a short-term (based on individual needs) program designed to assist individuals so that they can learn to manage their overall health and wellness, and be able to meet their needs on their own.
  • We help individuals work through crises, stabilize, and coordinate services so that supports are in place for continued wellness.
  • Care Management does not provide housing or transportation.

Contact

Have a question about our community services program?  Reach out to our team. 

Program Supervisor

Kim Anglestein

(315) 598-3980 ext. 228

kanglestein@ccoswego.com

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Hours

Monday - Friday

8:00 am– 4:00 pm



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