Children’s Health Homes

What is Children’s Health Homes?

Children’s Health Homes is a New York State program that provides comprehensive services to youth, age birth to 21, who are Medicaid recipients and have at least 2 chronic health conditions, a diagnosed severe mental illness, HIV/AIDS, or meet the definition of complex trauma.

The medical world can be daunting and overwhelming at times, and we are here to help youth and their families navigate the system.

Eligible youth and their family will be assigned 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. This care manager also ensures that all of the youth’s medical caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive and timely manner.

Eligibility is determined by the following:

  • Care Management assistance is provided for MEDICAID ENROLLED youth—an active Medicaid Health Plan must be in place—that are in need of assistance to better manage their diagnosis.
  • Two or more chronic conditions OR One single qualifying chronic condition: HIV/AIDS or Serious Emotional Disturbance (SED) or Complex Trauma
  • In addition, the Medicaid member must be appropriate for the intensive level of care management services provided by Health Home, i.e., satisfy appropriateness criteria

Health Home:

There are over 130 Health Homes across New York State. The 2 in Ulster County are: Institute for Family Health and CHHUNY. Referrals can be sent directly to these health homes, if you are unsure of what CMA to send it to.

Care Management Agency:

Care Management Agencies consists of the Direct Care Management Support. Within the CMA’s, each client will be assigned to a Care Manager whom will coordinate their services. *Referrals are preferred to be sent directly to a CMA, if you know of one*
Example: Family of Woodstock is a CMA!

Health Homes Process:

  1. Referral is made for client in need. Referral should include verbal consent from parent/ guardian or Client ( if 18)
  2. Referral can be sent directly to a CMA (Family of Woodstock, Inc.), where it will be uploaded into MAPP— or—It can be sent to a Health Home Program, where it will also be uploaded into MAPP and then assigned to a CMA. * MAPP is the referral portal for all Health Homes*
  3. Once referral is received and uploaded by the CMA, outreach can begin. Outreach can last for up to 3 Months.
  4. Health Homes does not have a “limit of service.” We can enroll more than once, and can be in place until the specific client no longer meets the eligibility criteria.


  • A duplication of services would only include Early Intervention or Home and Community Based Waiver Services and any other MEDICAID FUNDED programs! Adult and Child Health Homes can be in place within the same residence!
  • Enrollment into Health Homes consists of consents to speak to many different providers within The Clients’ social support network. These consents are required in order to provide services.
  • If a client is 18 (or if they are a parent), they have the choice between Children and Adult Health Homes.
  • Complex Trauma: IF you believe a referral would qualify for the Complex Trauma Eligibility, the Complex Trauma Screen needs to be completed along with the referral.
  • The referral packet does not need to be completed entirely, but must include consent to be referred, name, and diagnosis.

To make a referral or for any questions, please contact
Nicole Martin (845) 331-7080 ext. 155 or Courtney Wyant (845) 331-7080 ext. 164