Health Home Program


About Health Home (HH) program

  • This program serves patients who receive Medicaid, are chronically ill, and require ongoing comprehensive care coordination services. Patients who enroll in the HH at IMA will receive these services from a Social Worker and a Patient Navigator (SW/PN). A HH team member will act as a point person for the patient and will assist him/her with needs related to medical health, behavioral health, and community support services. They can assist the patient in the clinic setting, as well as through accompaniments to appointments or entitlements offices, or through home visits when needed.

Eligibility criteria

  • Active Medicaid,
  • 2 or more chronic conditions, OR
  • 1 qualifying condition, defined as either HIV/AIDS or a serious and persistent mental illness.

How to refer a patient

A consult can also be made to Mount Sinai Health Partners Care Management via EPIC ORDER Referral to MSHP Care Management Order ID: 391414