Mount Sinai Health Home
Mount Sinai Health Home is a free service that integrates and coordinates health care for Medicaid patients. Funded by the New York Department of Health, the program is designed to improve the quality of care while lowering cost.
Once you enroll in Mount Sinai Health Home, you will be assigned a care coordinator. Your care coordinator will oversee and coordinate any health care services you may require. Working together, you and your care coordinator will develop a care plan that addresses any medical, mental health, and social service needs you may have. Your care coordinator is there to help you get the most out of your plan, improve your health, and take ownership of your care. Other services provided by our care coordinators include:
- Connecting all elements of care including primary care doctors, specialists, housing programs, social workers, mental health providers, substance use and addiction services, and HIV services
- Identifying additional ways to maintain health and access to care
- Finding and selecting services that better support improved health and ongoing health maintenance
- Assisting with appointments and scheduling transportation
- Helping members adhere to appointment and medication schedules
- Improving efficiency while decreasing overuse of services
- Transitioning members from hospitals to the community
Enrolling in Mount Sinai Health Home does not change your insurance, providers, or benefits. The program is voluntary – you can withdraw consent at any time.
Those interested in the Mount Sinai Health Home program may apply directly.
To participate, you must:
- Require assistance with health care system, housing, benefits, and chronic disease management and support
- Reside in Manhattan, Brooklyn, the Bronx, or Queens
- Possess active Medicaid status
- Have two or more chronic illnesses, HIV or AIDS, or a severe mental illness
If you are referring someone to our program, please use the appropriate form:
Please note that takes us two to three days to process a referral and assign an appropriate care coordinator and team.
The U.S. Department of Health requires all health home programs to subcontract with community-based organizations to provide outreach and care coordination on behalf of Mount Sinai Health Home. The following community based agencies are a direct extension of Mount Sinai Health Home and are contracted to provide ongoing care coordination:
- Allied Service Center of NYC (ASCNYC)
- Apicha Community Health Center
Venus Vacharakitja, MA
- Argus Community
- Association for Rehab Case Management and Housing (also known as ACMH)
- Bailey House
- Callen-Lorde Community Health Center
- Center for Urban Community Services (also known as CUCS)
- The Dennelisse LHCSA
Donald R. Powell
Tel: 212-243-3434 ext.145
- Fortune Society
- Isabella Geriatric Center
- Lower East Side Service Center (also known as LESC)
- Mount Sinai Beth Israel—Blended Case Management Program
- Mount Sinai Health System Care Coordination
Tel: 212-986-1170 ext. 121
- Pesach Tikvah
- Premier Home Health Care
- Project Renewal
Tel: 212-620-0340 ext. 494
- The Puerto Rican Family Institute, Inc.
- Village Care
- VIP Community Services
- William F. Ryan Community Health Network
Those interested in becoming a network provider should contact Kristina Monti.