Referral to CASES Health Home Care Management

Health Home Plus (HH+) is an intensive Health Home Care Management (HHCM) service established for defined populations with Serious Mental Illness (SMI) who may benefit from enhanced support because of high needs, disengagement from care, and/or poor outcomes (e.g., multiple hospitalizations, incarceration, and homelessness). 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. The length of HH+ participation is determined by ongoing assessment and review of individual progress in the community. Eligibility Criteria: HH+ services will be available for adults receiving Medicaid that are diagnosed with Serious Mental Illness and who meet certain indicators for high need, such as risk for disengagement from care and/or poor outcomes (e.g., multiple hospitalizations, re-entry from incarceration, and homelessness).

Referral Date(Required)

Client First Name(Required)

Client Last Name(Required)

Gender(Required)

Identifies as Male

Identifies as Female

Female-to-Male (FTM)/Transgender Male/Trans Man

Male-to-Female (MTF)/Transgender Female/Trans Woman

Genderqueer, neither exclusively male nor female

Additional gender category or other, please specify

Choose not to disclose

Please Specify

Date of Birth(Required)

Client/Contact Phone Number(Required)

Phone Number Type(Required)

Cell Phone

Home

Other

Address(Required)

Street Address Address Line 2 City State ZIP Code

Race(Required)

Ethnicity(Required)

Non-Hispanic

Hispanic

Primary Language(Required)

English

Spanish

Other

Reason Seeking Service(Required)

Social Security Number

Needed to determine eligibility for services

Medicaid ID Number(Required)

Needed to determine eligibility for services

Referral Source(Required)

Self

CASES Program

Other Agency

Referring Program(Required)

Other

Client ID

e.g., AWARDS ID or Salesforce PCID for CASES Programs

Contact Name(Required)

(first and last name of person making the referral)

Referral Source - Phone Number(Required)

Referral Source - Email Address(Required)

NYSID ID# if person being referred has forensic involvement

(i.e Parole, probation, recently incarcerated, Court involvement etc.)

Agency Name(Required)

Is this referral for a client who is being discharged from an inpatient psychiatric hospital?

Yes

Is this referral from a criminal justice agency?(Required)

Yes

Supporting documentation for this referral and information release instructions.

Please send supporting documentation for this referral (e.g., hospital discharge summary, medication list, previous psychiatric/psychosocial assessments) via email (caremanagement@cases.org) or fax (646-863-4167). If you anticipate asking the Health Home Care Management program for health-related information such as written or verbal information about your client’s attendance or progress, please send a completed HIPAA consent form such as OMH 11(c) via email (caremanagement@cases.org) or fax (646-863-4167). Your client must specifically consent to the Health Home Care Management program's release of mental health information, alcohol/drug treatment information, and HIV/AIDS information. OMH 11(c) is available at: https://omh.ny.gov/omhweb/hipaa/manual/appendix3.pdf

How did you hear about Health Home Care Management at CASES?(Required)

File

Max. file size: 64 MB.