Health Home Program (HH)

Our Health Home program offers compassionate, highly coordinated care designed to support your overall well-being and help you seamlessly navigate the complexities of the healthcare system.

This program expands upon broader efforts to fully integrate physical (somatic) and behavioral health services for individuals with chronic conditions.

A Community-Based Approach to Care

This is a community-based support initiative, not a residential program. It specifically targets populations with behavioral health needs who face a high risk of developing additional chronic health issues, including individuals managing:

• Serious persistent mental illness

• Serious emotional disturbances

• Opioid and substance use disorders

We offer enhanced care coordination to clients who already regularly receive foundational care—such as psychiatric rehabilitation programs, mobile treatment services, and opioid treatment. By emphasizing person-centered care, we empower participants to actively manage and prevent chronic conditions, drastically improving long-term health outcomes while reducing avoidable emergency room visits and hospital stays.

Our Six Core Services

To deliver comprehensive, holistic support, our Health Home program relies on six foundational services:

• Comprehensive Care Management: Building tailored health strategies to oversee and guide your total wellness plan.

• Care Coordination: Seamlessly connecting your doctors, specialists, and behavioral health providers to keep everyone on the same page.

• Health Promotion: Providing the education, tools, and resources you need to make healthy lifestyle choices and prevent illness.

• Comprehensive Traditional Care: Overseeing smooth transitions between different care settings, such as moving safely from a hospital back to your home.

• Individual and Family Support: Empowering both you and your loved ones with the guidance and advocacy needed to manage your health journey together.

• Referrals to Community and Social Support: Connecting you with vital local resources, including housing assistance, food programs, and legal or social services.