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AHI Health Home Care Management

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.


Read Success Stories to see how the AHI Health Home Care Management program has positively impacted the lives of our community members.

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 Counties ServedSpecialtiesPopulation (age)
Alliance for Positive HealthClintonFoster Care, Sever Emotional Disturbance, AOT, HARPAdults and Children
CapitalCapital District Psychiatric Center District Psychiatric CenterEmbedded into GFHFormer OMH, Sever Emotional DisturbanceAdults and Children
UVMHN/ Champlain Valley Health NetwUVMHN/ Champlain Valley Health NetworkorkClinton, Essex, and FranklinComplex Medical Needs, Transition of Care, Primary CareAdults
Citizen Advocates/Northstar BehavioralCitizen Advocates/Northstar Behavioral Health Services Health ServicesFranklin (*+parts of Clinton, Essex, and St. Lawrence)Severe Emotional Disturbance, AOT, HARPAdults and Children
Community Maternity ServicesWarren and WashingtonFoster care, Child WelfareAdults and Children
Essex County Mental Health ServicesEssexBehavioral Health, HARPAdults
Families First in EssexEssexSevere Emotional DisturbanceChildren
Glens Falls HospitalWarren, and WashingtonSevere Emotional Disturbance, Complex Medical Needs, HARPAdults and Children
Hamilton County Community ServicesHamiltonBehavioral Health, HARPAdults
HCR Care Management LLCClinton, Essex, Franklin, St. Lawrence, Warren, and WashingtonComplex Medical, Transition care, HARPAdults
Hudson Headwaters Health NetworkClinton, Essex, Hamilton, Warren, WashingtonComplex Medical, Primary Care, Transition careAdults and Children
Mental Health Association in Essex CountyEssexBehavioral Health, HARPAdults
St. Anne InstituteClinton, Warren, and WashingtonFoster CareChildren
St. Lawrence Psychiatric CenterEmbedded into BHSNFormer OMHAdults and Children
Transitional Services AssociationWarren and WashingtonAOTAdults
United Helpers MosaicSt. LawrenceACT, HARPAdults and Children
Warren-Washington Association for Mental HealthWarren and WashingtonSerious and Persistent Mental Illness, Severe Emotional Disturbance, HARPAdults and Children