“Does our client need someone to accompany them to their doctor’s appointment? Does our client need help scheduling an appointment at their local HRA office for additional resources? Many times, our Care Manager is functioning as a supportive family member,” explained HeartShare Health Home Director Silvia Estrada. Health Home connects patients with appropriate physicians, coordinates appointments among specialists, helps with their housing search and assists with designating available benefits.

Today, HeartShare’s Health Home program has doubled in size under Estrada’s leadership and now serves approximately 520 clients in the five boroughs, which may include those with HIV/AIDS, but more broadly patients with two or more chronic conditions, including diabetes, asthma or severe depression. Many of Health Home’s clients, due to the requirement of two or more chronic conditions to participate, happen to be older. “Health Home functions as a hub of resources that ensures that the patient achieves stability and reduces the possibility of hospitalization,” noted Estrada.