Solutions for Health Homes
Contact: Marshall Ellis, Director of
Outreach & Partnership Development, (212) 614-6376, mellis@mhaofnyc.org
MHA-NYC is a leader in developing innovative approaches to
address behavioral health needs. MHA-NYC has its roots in New York
City, but growing demand has resulted in a need for our innovative
services well beyond New York City's borders.
MHA-NYC's LifeNet is a leader in a national effort to design,
evaluate, and implement effective behavioral health interventions
using communication technology-telephone, SMS texting, and
real-time web chats-to improve health outcomes of disengaged and
high risk individuals by getting, and keeping, them linked to
care.
LifeNet can be an invaluable resource to health home providers
seeking to deliver high quality, cost-effective medium- to
low-intensity case management services to health home enrollees
with chronic conditions.
Comprehensive Care Management
- Outreach and engagement activities to support patient
engagement in treatment and to promote continuity of care
Care Coordination and Health Promotion
- Evidence-based referrals and follow-up services
- After-hours access to information and emergency consultation
services
- Appointment reminders to ensure patients follow through with
treatment plans
Comprehensive Transitional Care
- Post-discharge transitional case management to support patient
compliance with treatment plan and improve continuity of care
- Outreach to re-engage patient, if needed
Patient and Family Support
- Facilitate connections to peer supports, support groups, and
self-care programs to increase patients' knowledge about their
disease, engagement, and self-management
Referral to Community Support Services
• Identify available community-based resources and
actively manage appropriate referrals, access, engagement,
follow-up, and coordination of services
• Support effective collaborations with
community-based resources
• Provide information on community-based and other
social support services and healthcare services that respond to the
patients' needs and preferences and contribute to achieving the
patients' goals