Health Home Program
One team keeping every part of your health talking to every other part.
What this program is — and who it's for
The Health Home Program exists because fragmented care fails people. Participants get a dedicated care team — a nurse care manager, care coordinator, and health home director — who track every part of their health and make sure nothing falls through the cracks.
The team monitors chronic conditions such as diabetes, hypertension, asthma, and obesity alongside behavioral health, coordinates with primary care and specialists, follows up after every hospitalization or ER visit, and helps participants actually get to their appointments.
Health Home is available to individuals already enrolled in our PRP or substance use programs, creating a single accountable point of contact for the whole person.
Who this program serves
- Individuals enrolled in PRP or an opioid treatment program
- People with a serious mental illness plus one or more chronic medical conditions
- Clients with frequent ER visits or hospital readmissions
- Anyone struggling to coordinate multiple providers on their own
Inside the program
Every element below is part of the plan we build with you — not an add-on.
Comprehensive Care Management
A single plan covering physical, behavioral, and social needs.
Care Coordination
Scheduling, records, and communication across every provider you see.
Health Promotion
Nutrition, exercise, smoking cessation, and chronic-disease self-management.
Transitional Care
Rapid follow-up after hospital discharge to prevent readmission.
Individual & Family Support
Education and advocacy for participants and the people who care for them.
Community Referrals
Housing, food, transportation, and benefits — linked and followed up.
How admission works
Reach out
Call us or submit the intake form. No referral needed to start the conversation.
Verify coverage
We check Medicaid or commercial benefits and handle authorizations.
Assessment
A clinician completes a full assessment and recommends the right level of care.
Begin care
Your plan is built with you, and services start — usually within days.
Frequently asked
Does Health Home replace my doctor?+
No. It coordinates around your existing providers and helps you use them effectively.
Is there a cost?+
For eligible Medicaid participants there is no additional cost for health home services.
How do I enroll?+
Enrollment happens through our intake team once eligibility in a qualifying program is confirmed.