New York State Health Foundation

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Health Homes

High-need patients struggling with chronic conditions often do not receive the consistent treatment needed to prevent complications. Through health homes, the Affordable Care Act provides states with a new tool to provide intensive coordinated services for Medicaid populations with multiple chronic conditions. A health home is a network of providers across a community, with the lead provider facilitating access to an array of medical, behavioral health, and social services. Health homes have the potential to reorganize how care is delivered, managed, and coordinated for high-need and high-cost patients. In turn, health homes could lead to lower emergency room use, fewer preventable hospital admissions and readmissions, reductions in high costs of care, and improved quality of care.

New York has been among the first states to adopt a Medicaid health home model. Early data for a subset of the health home population in New York show that primary care visits increased by 14%, while inpatient admissions and emergency department visits decreased by 23%. NYSHealth is supporting grantees who are working to expand operating capacity, improve cross-sector care coordination, and develop and share evidence on effective program design and implementation strategies.

Learn more about some initiatives NYSHealth has supported in this area:

Center for Health Care Strategies, Inc.
  •  New York State Health Homes Learning Collaborative, Phase 1
  •  New York State Health Homes Learning Collaborative, Phase 2
  •  New York State Health Homes Learning Collaborative, Phase 3
  •  Advancing Health Homes in New York: Identifying Best Practices in Recruitment and Engagement & Promoting Sustainability

Corporation for Supportive Housing
Building Health Home Capacity to Serve Homeless Clients

New York University McSilver Institute for Poverty, Policy, and Research
30 Years of Integrating HIV Prevention & Care—Implications for the Creation & Implementation of Health Homes

Adirondack Health Institute, Inc.
Sustaining the Success of the Primary Care Medical Home Model in the Adirondacks

Columbia University Mailman School of Public Health
Advancing the Integration of Community Health Workers into Patient-Centered Medical Homes and Health Homes in New York State


NYSHealth has supported other reports that take a look at the experiences and lessons learned to date of New York State's health home initiative:

  •  "Care Management in New York State Health Homes"
  •  "Making the Connection: The Role of Community Health Workers in Health Homes"
  •  "Outreach to High-Need, High-Cost Individuals: Best Practices for New York Health Homes"
  •  "Seizing the Opportunity: Early Medicaid Health Home Lessons"


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