Primary Care

Project Title

Lessons: 30 Years of Integrating HIV Prevention & Care— Implications for the Creation & Implementation of Health Homes

Grant Amount


Priority Area

Primary Care

Date Awarded

October 7, 2013







In New York State, the primary health care system is at a generational crossroads—with the Affordable Care Act and mental health parity laws, more individuals will be eligible for primary and behavioral health care, but costs for those with the most complex needs are expected to rise exponentially without policy- and provider-level interventions.

New York State Medicaid health homes can improve care for patients struggling with complex physical and behavioral health challenges, while simultaneously containing costs. Lessons learned from previous attempts at care coordination, particularly from the design efforts of HIV systems, can provide insight into the successful implementation of health homes. NYHealth awarded New York University McSilver Institute for Poverty Policy and Research (McSilver) a grant to produce a report that offers recommendations for the development of health homes with a specific focus on patients with serious mental illness.

Under this grant, McSilver summarized lessons learned from HIV prevention, care, and case management models to inform health home provider organizations on care coordination and implementation strategies for patients with serious mental illness. The final report offered recommendations that included practice innovations for health homes to consider; changes in organizational processes and procedures, including expanded workforce options such as peer care specialists and health navigators; established and shared best practices and quality improvement strategies; and strategies for collaborative, coordinated care management.