Organizational Transformation

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AHI is a New York State-designated lead Health Home and serves all ages. A Health Home is not a place; it is a care management service that connects community and social supports with health care, and provides better organization of medical and behavioral health care. A Health Home ensures all caregivers involved with a person talk to one another so they can focus on their client’s needs.

Our Role

We coordinate medical and behavioral health care by connecting community and social supports with health care for high-risk Medicaid members with:

  • HIV/AIDS; or
  • a serious persistent mental illness; or
  • two or more other chronic conditions.

Additionally, any of the following risk factors must be a part of the person’s situation. These reasons include, but are not limited to:

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


The AHI Health Home Care Management program goal is to improve care coordination for high-risk Medicaid individuals, reduce duplicative services, reduce emergency department visits and inpatient admissions, and lower costs.

The AHI Heath Home Care Management program is a partnership of primary care providers, hospitals, and several behavioral health and community-based organizations.

Contact Us

For more information about the AHI Health Home Care Management program, call 866.708.2912 or email [email protected].

Complete the AHI Health Home Community Referral Form.


Care Management Agency (CMA Name)Counties ServedSpecialtiesPopulation (Age)
Alliance for Positive HealthClinton, Essex, Warren, and WashingtonHIV/AIDS, HARPAdults
Behavioral Health Services NorthClintonFoster Care, Severe Emotional Disturbance, HARPAdults and Children
Capital District Psychiatric CenterEmbedded into GFHFormer OMH, Severe Emotional DisturbanceAdults and Children
Citizen Advocates/North Star Behavioral Health ServicesFranklin (+ parts of Clinton, Essex, and St. Lawrence)Severe Emotional Disturbance, HARPAdults and Children
Community Maternity ServicesWarren and WashingtonFoster Care, Child WelfareAdults and Children
Essex County Mental Health ServicesEssexBehavioral Health, HARPAdults
Families First in Essex CountyEssexSevere Emotional DisturbanceChildren
Glens Falls HospitalWarren and WashingtonSevere Emotional Disturbance, Complex Medical Needs, HARPAdults and Children
Hamilton County Community ServicesHamiltonBehavioral HealthAdults
HCR Care Management LLCClinton, Essex, Warren, and WashingtonComplex Medical, Transition Care, HARPAdults
Hudson Headwaters Health NetworkClinton, Essex, Hamilton, Warren, and WashingtonComplex Medical, Primary Care, Transition CareAdults and Children
Mental Health Association in Essex CountyEssexBehavioral Health, HARPAdults
St. Anne InstituteClinton, Warren, and WashingtonFoster Care, Severe Emotional Disturbance, Behavioral HealthChildren
St. Lawrence Psychiatric CenterEmbedded into BHSNFormer OMHAdults and Children
Transitional Services AssociationWarren and WashingtonAssisted Outpatient TreatmentAdults
United Helpers MosaicSt. LawrenceAssertive Community Treatment, HARPAdults and Children
UVMHN/Champlain Valley Health NetworkClinton, Essex, and FranklinComplex Medical NeedsAdults
Warren-Washington Association for Mental HealthWarren and WashingtonSevere Emotional Disturbance, HARPAdults and Children
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