Health Home Plus Care Management

The Intervention: Care management services

Who is Served: Adult Medicaid recipients living with serious mental illness (SMI) and high needs including criminal justice involvement (see below for detailed eligibility)

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The Challenge

On average, 80% of people released from prison in the United States each year have a substance use disorder or chronic medical or psychiatric condition.1 For many of these individuals, these health concerns went unaddressed and/or worsened while incarcerated. Though studies also indicate that incarcerated and newly-released individuals have more serious physical and behavioral health needs than the general population, Medicaid is suspended during the tenure of a person’s incarceration, which means that those reentering the community must reapply for healthcare benefits.2 Navigating this bureaucratic process—along with the other challenges posed by reentry—can be a significant barrier.

In 2011, New York’s Health Home program was created at the recommendation of Governor Cuomo’s Medicaid Redesign Team to serve Medicaid recipients unable to find and maintain engagement in health care services. Health Home Plus (HH+) Care Management was subsequently introduced in 2014 to target the Assisted Outpatient Treatment (AOT) population, who have court-ordered treatment to previous difficulty engaging in rehabilitation and evidence of posing a risk to themselves or others in the community. Currently, any Medicaid recipient with SMI is eligible for HH+ if he or she also has a “high need” including any of the following:

  • Transitioning from Assertive Community Treatment (ACT) to a lower level of service (e.g., outpatient mental health clinic, etc.)
  • History of an expired AOT court order within the past year
  • Homelessness, defined as any of the following
    • A primary nighttime residence that is public or private and not meant for human habitation
    • Living in a shelter designated for temporary housing
    • Exiting an institution resided in for 90 days or less including an emergency shelter
  • High utilization of inpatient/emergency department (ED) services, defined as any of the following
    • 3+ psychiatric inpatient hospitalizations within the past year
    • 4+ psychiatric ED visits within the past year

CASES specifically targeted HH+ Care Management as an opportunity to serve two priority populations:

  1. criminal justice-involved persons with SMI, a population researchers have found is 40% more likely to have a chronic medical problem than the general population
  2. individuals who have successfully completed intensive treatment services in one of CASES’ six ACT programs and could benefit from the step down to ongoing support via HH+ Care Management

The Health Homes Plus Care Management Approach

HH+ care managers work directly with individuals in the community to help them establish and maintain participation in the services they need to address their treatment, social, and health needs. Care managers attend appointments with participants and help them to acquire skills that promote successful community living. Participants receive guidance on learning to manage challenges related to mental and physical illness, reducing visits to emergency rooms and inpatient hospitalizations, reducing risky behaviors including substance use that can lead to involvement in the criminal justice system, and achieving stability and safety as fully-integrated members of the community. The length of HH+ participation is determined by ongoing assessment and review of individual progress in the community. Services provided by CASES’ HH+ Care Management include:

  • 4+ core services per month, including 2+ face-to-face contacts
  • Comprehensive clinical assessment and treatment planning
  • Continuous assessment to identify and develop proactive solutions for needs and risks
  • Increased service contacts when required by an individual’s immediate need
  • Care coordination and health promotion, including comprehensive transitional care
  • Help maintaining Medicaid benefits
  • Assistance with obtaining and maintaining housing that is safe, affordable, and based on the participant’s choices and preferences
  • Referrals to community and social supports

The Impact

CASES initiated HH+ Care Management services in early 2019. We expect that the program will enroll at least 60 participants this year, gradually growing over the coming years to a continuous, active caseload of 120 participants. Researchers have identified that formerly-incarcerated individuals with chronic health needs have about half as many emergency departments visits when they work with community care management specialists than those who do not.3 Such a change in healthcare also correlates with savings in public health and public safety expenses and vast improvements in quality of life.


1 The City of New York. (2015). “State Strategies for Establishing Connections to Health Care for Justice-Involved Populations: The Central Role of Medicaid.” Retrieved from ^

2 Mallik-Kane, K., & Wishner, Jane B. (2016). New Medicaid guidance could help people get much-needed health care after prison or jail. Urban Wire: The Blog of The Urban Institute. Retrieved from ^

3 “States Try New Approaches to Connecting Formerly Incarcerated Individuals with Healthcare.” AJMC. Retrieved from ^