Care Coordination

The primary responsibility of the Care Coordination (Case Management) program is to work with enrolled members (you do NOT have to be a Horizon patient) to manage complex and chronic health care needs. Care Coordination provides outreach, engagement and care management services to eligible members enrolled in New York’s Medicaid program. This program will ensure that a comprehensive health-based needs assessment will be completed to determine the member’s physical, behavioral health and social needs.

Our team oversees implementation of the plan of care by providing:

• Coordination, collaboration, and continuity with all community providers.
• Referrals and linkages to areas such as public entitlements, housing, medical/behavioral health educational/vocational services and community resources such as food, clothing, utility assistance.
• Member and family education to increase understanding and encouragement of the member assuming an active role in managing their health.
• Encouragement to engage in primary and preventative care to avoid emergency room visits/ hospital stays.
• Health and recovery plan services. We work closely with members managed care plan to link with home and community-based services. These are enhanced services available through a members Managed Care Plan if one qualifies

Our Care Coordination team works collaboratively with members’ clinical caregivers to support the members achieving their treatment and rehabilitation goals.