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

  • 212-523-1897
  • They will ensure that the patient is eligible and is not receiving HH services elsewhere. They will then assign the case to a SW/PN team.

  • Alternatively, you can refer the pt to SW triage and he/she will assess the pt for eligibility. Click here for social work referral.

*Note: If a patient is appropriate for IMA PACT and HH services, a referral should be made to IMA PACT only, and will be assessed for HH enrollment by the SW at the initial appointment. Click here for information about the PACT program.