Program Information
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.
Health Homes Explained
Our Goal
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.
By connecting high-risk Medicaid individuals to resources and supports, we aim to reduce duplicate services, reduce emergency department visits and inpatient admissions, and lower costs, thus improving the health and wellbeing of lives throughout the North Country.
More About AHI Health Home
AHI Health Home’s Role: AHI’s Lead Health Home hosts monthly meetings for our region’s care management agencies to review NYS Department of Health (DOH) policies and procedures, collaborate to review areas for improvement, and share best practices.
Objective: The AHI Health Home is a partnership with primary care providers, hospitals, community-based organizations, and several behavioral health organizations.
Cost: AHI Health Home care management services are funded by Medicaid and Medicaid Managed Care. There is no out of pocket cost for Health Home participants.
who is it for?
AHI Health Home offers support for individuals seeking:
*including but not limited to
• Home & Community Based Services
• Mental Health Services
• Food
• Substance Use Treatment
• Child & Family Advocacy
• Medical Service
• Transportation
• Housing
• Benefits/Health Insurance
Individuals interested in Health Home Care Management services must meet specific criteria to be eligible.
Adults and Children must:
Have active Medicaid; and meet condition criteria.
In addition to having Medicaid and two or more Chronic Conditions, one or more of the below risk factors must be a component of an individual’s circumstances.
Qualifying conditions may include:
• HIV/AIDS
• Severe Emotional Disturbance (children)
• Complex Trauma (children)
• Sickle Cell Disease
• Serious Mental Illness
AHI’s Lead Health Home serves clients in the following counties: Clinton, Essex, Franklin, Fulton, Hamilton, Montgomery, Saratoga, St. Lawrence, Warren, and Washington.
Contact Us
The AHI Heath Home Care Management program is a partnership of primary care providers, hospitals, and several behavioral health and community-based organizations.
For more information about AHI’s Health Home/Care Management program, call 866.708.2912, or email healthhome@ahihealth.org.
To make a referral to AHI’s Health Home, click below and complete the appropriate form:
FAQ
AHI Health Home Care Management Forms
Forms
Below are forms related to the AHI Health Home Care Management program.
Referral Form
- Health Home Care Management Community Referral/Transfer Form for Adults and Children
- Bottom Up Referral Form for Health Home Care Management
Incident Report Form
Disenrollment Forms
- AHI Health Home Care Management Discharge Summary
- AHI Health Home Disenrollment
- Continuity of Care and Re-engagement for Enrolled Health Home Members
- Discharge Checklist – Adults
- Discharge Checklist – Children
- Disenrollment Desk Guide
Agency Self Audit Forms
Children’s Health Home Annual Comprehensive Chart Review Tool
Health Home Children Care Manager Personnel Record Checklist
Other Forms
- DOH Forms for Adults
- DOH Forms for Children
- Health Home Patient Information Sharing Consent
- Health Home Plus Attestation for Serious Mental Illness
- Local Government Unit/Single Point of Access and Care Management Agency Working Relationship Form
- Minor Protected Services
- Systems Access Request Form
- Welcome to Adirondack Health Institute
For more information about the AHI Health Home Care Management program, call 866.708.2912, or email healthhome@ahihealth.org.
AHI Health Home Netsmart Manuals and Forms
Below are training materials for the AHI Health Home Care Management program.
- Netsmart CareManager User Manual – Adult Health Home
- Netsmart CareManager User Manual – Children’s Health Home
Below are paper versions of the Comprehensive Assessment. Please be sure to upload the completed version into Assessments and complete the Comprehensive Assessment in Netsmart.
For more information about the AHI Health Home Care Management program, call 866.708.2912, or email healthhome@ahihealth.org.
AHI Health Home Care Management Training Videos
Training Videos
Adult Consent
- Consent Introduction
- DOH 5236-DOH 5059
- DOH 5234
- DOH 5055
- Hixny Consent
- DOH 5058-DOH 5235
- When to Get a New Consent
- Consents in Netsmart
- Wrap Up Lessons Learned
Children’s Consent
- Welcome
- NOD Denial of Enrollment
- Opt-Out Form
- DOH 5200
- 5201 Section 1
- 5201 Section 2
- 5201 Wrap Up
- FAQ
- Hixny
- NOD Enrollment
- Functional Assessment
- Release of Educational Records
- Withdrawal of Educational Consent
- Withdrawing Consent
- Getting New Consent
- Wrap Up
- Netsmart Consent Walkthrough
- Thank You
Comprehensive Assessment Health-Related Social Needs Screening Tool
Billing at the Right Rate: How to Complete the HML/CBQ
HARP
Data Den
HML in Netsmart
Making a Referral
Netsmart New User Training
- Netsmart New User Training 1
- Netsmart New User Training 2
- Netsmart New User Training 3
- Netsmart New User Training 4
- Netsmart Multi-factor Authentication
- Okta Login Using Okta Verify
- Okta Login Using SMS Authentication
Office Hours
- January 2019 Office Hours
- February 2019 Office Hours
- March 2019 Office Hours
- April 2019 Office Hours
- May 2019 Office Hours
- October 2019 Office Hours
- March 2020 Office Hours
- AHI Health Home March 2020 Quarterly Leadership Zoom Meeting
- April 2020 Office Hours
- May 2020 Office Hours
- AHI Health Home June 2020 Quarterly Leadership Zoom Meeting
- July 2020 Office Hours
- August 2020 Office Hours
- AHI Health Home September 2020 Quarterly Leadership Zoom Meeting
- October 2020 Office Hours
- November 2020 Office Hours
- January 2021 Office Hours
- February 2021 Office Hours
- March 2021 Office Hours
- April 2021 Office Hours
- May 2021 Office Hours
- June 2021 Office Hours
- July 2021 Office Hours
- August 2021 Office Hours
- September 2021 Office Hours
- October 2021 Office Hours
- November 2021 Office Hours
- January 2022 Office Hours
- February 2022 Office Hours
- March 2022 Office Hours
- April 2022 Office Hours
- May 2022 Office Hours
- June 2022 Office Hours
- July 2022 Office Hours
- August 2022 Office Hours
- September 2022 Office Hours
- October 2022 Office Hours
- November 2022 Office Hours
- January 2023 Office Hours
- February 2023 Office Hours
- March 2023 Office Hours
- April 2023 Office Hours
- May 2023 Office Hours
- June 2023 Office Hours
- July 2023 Office Hours
- September 2023 Office Hours
- October 2023 Office Hours
- November 2023 Office Hours
- January 2024 Office Hours
- February 2024 Office Hours
- March 2024 Office Hours
- April 2024 Office Hours
- June 2024 Office Hours
- July 2024 Office Hours
- August 2024 Office Hours
- September 2024 Office Hours
- October 2024 Office Hours
- November 2024 Office Hours
- January 2025 Office Hours
- February 2025 Office Hours
Plan of Care Training: Adults and Children
- Plan of Care – Introduction
- Module 1 – Care Planning Theory
- Module 2 – Assessments for Care Planning
- Module 3 – Developing a Plan of Care
- Module 4 – Goals
- Module 5 – Objectives and Notes
- Module 6 – Amending the Plan of Care
Report Training
Special Office Hours
- Verbal and Written Consents During the COVID-19 State of Emergency
- Continued Eligibility for Services – CES Tool
- November 18th, 2024 Special Office Hours
- December 9th, 2024 Special Office Hours
Other Resources
AHI Health Home Care Management Policies and Procedures
Policies and Procedures
Below are policies and procedures related to the AHI Health Home Care Management program.
- Access to Services
- Activities and Billing Protocols for Newly-Referred Members in an Excluded Setting
- CANS-NY Assessment
- Care Transitions
- HCBS Waiver Disenrollment and Discharge
- Children’s Waiver and HCBS Policy
- Children’s HCBS Waiver Authorization Policy for FFS Members
- Children’s Plan of Care
- Complaints
- Comprehensive Assessment
- Conflict-Free Case Management
- Continuity of Care and Re-engagement for Enrolled Health Home Members
- Eligibility and Appropriateness Criteria
- HARP Oversight
- Health Home Billing
- Health Home Disenrollment
- Health Home Outreach and Engagement
- Health Home Plus for HIV/AIDS
- HH+ SMI and AOT
- Health Home Referrals and Assignments
- Health Home Serving Children and Children and Youth Evaluation Services (C-YES) Transfer and Referral
- Health Home Supervisor and Caseload Ratios
- Health Home Transfer
- HHSC Waiver Adaptive and Assistive Equipment, Environmental and Vehicle Modifications
- Home and Community-Based Services Children’s Waiver Participant’s Rights and Choice
- Home Systems Access and Identity Assurance policy
- Homeless Youth Services Consent Policy
- Incident Reporting and Monitoring
- Health Home Informed Consent
- Interpreter Services
- Maintaining OPWDD ICF/IID Level of Care Eligibility Determination Policy
- Non-Health Home Program
- Notice of Determination and Fair Hearing Policy for Health Home and HCBS
- Plans of Care – Adults
- Palliative Care Policy
- Quality Assurance and Performance Improvement
- Staffing Qualifications
- Transfer Process between HHSC and OPWDD Comprehensive Waiver
For more information about the AHI Health Home Care Management program, call 866.708.2912, or email healthhome@ahihealth.org.
AHI Health home Partners
See the full list of AHI Health home Partners Here
