Primary Care

Grantee Name

Center for Health Care Strategies, Inc.

Funding Area

Primary Care

Publication Date

June 2015

Grant Amount


Grant Date:

September 2013 – August 2014

The implementation of Medicaid health homes represents a major delivery system transformation effort on the part of the State to provide integrated care management and care coordination for patients with multiple chronic health needs.

However, recruitment and engagement efforts are often challenged by an array of psychological barriers experienced by the individuals who stand to benefit the most from health home services—particularly those whose health care service utilization and associated costs are likely to be impacted by the newly available care coordination and management services.

NYHealth awarded Center for Health Care Strategies (CHCS) a grant to identify reimbursement and engagement strategies to address the challenges, best practices, and sustainability for health homes. The grant also supported, in partnership with the Missouri Foundation for Health, a meeting to convene representatives from states that were early adopters of health homes and discuss key factors of health home implementation and maintenance.

Outcomes and Lessons Learned

  • Identified seven promising practices for recruiting patients with complex medical and behavioral health needs into health homes;
  • Produced the report, “Outreach to High-Need, High-Cost Individuals: Best Practices for New York Health Homes,” and disseminated it directly to health home agencies through the New York State Health Home Learning Collaborative and to a broad audience of other stakeholders; 
  • Shared important lessons about designing and implementing health homes for individuals with complex medical and behavioral health care needs;
  • Published the report, “Seizing the Opportunity: Early Medicaid Health Home Lessons,” which was distributed widely by NYHealth, Missouri Health Foundation, and CHCS; and
  • Held a webinar in April 2014 to distill these lessons to a national audience, using contacts from its work at Centers for Medicare & Medicaid Services and from each foundation. The webinar, which featured speakers from both foundations, attracted a national audience of nearly 400 participants.

The reports are expected to influence the continued implementation of State health homes, as well as to help refine the design and implementation of the State’s new children’s health home model to be established in late 2015. Both reports brought increased national attention to New York’s efforts, garnering support among policymakers and providers and reinforcing the notion that New York is breaking new and important ground on care for high-need, high-cost individuals through its health home initiative.