“One of our greatest assets at Health Home is the expertise of the people on our team,” explained HeartShare Health Home Director Silvia Estrada. Health Home serves approximately 520 clients in the five boroughs with two or more chronic conditions, such as HIV/AIDS, diabetes, asthma or severe depression. The program was designed to reduce the number of hospitalizations and Emergency Room visits for this group and in turn, stabilizing their health and quality of life. The Health Home Case Navigator team goes out into the community to pursue outreach through home visits followed up by calls and letters. Within 24 hours of enrollment into the HeartShare program, the Care Manager initiates a plan of action for improved health care, including scheduling a home visit, assessing the patient’s health, establishing a care plan and goals, as well as initiating communication with the patient’s physicians.

Health Home connects a patient with appropriate physicians, coordinates appointments with specialists, helps with their housing search and researches available benefits. “Care Managers often function as supportive family members. Does our client need someone to accompany them to the doctor? Does our client need help getting in touch with their local HRA office? Health Home functions as a hub of resources, so that the patient achieves stability,” explained Estrada.