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Care Management

Health Home Program is a free program serving both adults and children that coordinates care for our Medicaid patients who have complex chronic diseases and behavioral health issues. While many Medicaid patients are relatively healthy, there are individuals whose conditions are more severe, requiring support and assistance in the community.

Health Home offers care coordination and integration that assures access to appropriate services, improves health and outcomes, while reducing hospitalizations and emergency room visits.

Through this model all of the professionals involved in your care, communicate with one another so that all medical, behavioral health and social service needs are handled in a coordinated, comprehensive manner. This is done primarily through a “care manager” who oversees and coordinates access to all of the services. Oversight and care coordination will reduce unnecessary emergency department visits and inpatients stays. Health records will be shared among providers so that services are not duplicated or neglected.

In addition to coordinating your medical services and appointments, Care Management connects you to other community supports, such as housing, food and legal services. Please call 315.326.3460.

Support System

Oswego Health’s Care Management team has highly trained care managers, for adults and children, who are qualified to assist you:

  • Coordinate your care through effective communication with other providers.
  • Advocate on your behalf so you receive the care you deserve.
  • Navigate the complex Healthcare system.
  • Link to resources for finding affordable housing, food, clothing, childcare and transportation.
  • Learn more about meaningful activities to improve your health and keep you healthy.
  • Identify your goals.

All based on individual needs and services.
We do what it takes to get you the support YOU need.

How do I Qualify?

Medicaid beneficiaries need to meet only one of the following conditions:

  • Living with HIV/AIDs or
  • A significant mental illness or
  • Two or more chronic health conditions, such as asthma, diabetes, heart disease, mental health condition or substance use disorder.

Additionally, any one or more of the following risk factors must exist:

  • homelessness or risk of homelessness
  • Lack of social/family support
  • Non-adherence to treatments
  • Learning or cognitive issues
  • Deficits in activities of daily living

Free for Medicaid recipients, including Managed Care Medicaid and those who have both Medicare & Medicaid.

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