Health Homes Care Coordination

Hudson Valley

Health Homes Care Coordination

Navigating the current health care system can be difficult for relatively healthy Medicaid recipients and even more so for enrollees who have high-cost and complex chronic conditions that drive a high volume of high-cost inpatient episodes.

What is a Health Home?

A Health Home is a care management service model whereby all of an individual’s caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner. This is done primarily through a “care manager” who oversees and provides access to all of the services an individual’s needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared among providers so that services are not duplicated or neglected.
Health Home services are provided through a network of organizations – providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual “Health Home.”

Who is Eligible to be in a Children’s Health Home?

Children from birth to age 21 must be enrolled in Medicaid AND meet eligibility criteria by having two or more chronic health conditions OR one of the following single qualifying conditions:

  • Serious Emotional Disturbance 
  • Complex Trauma

What does a Children’s Health Home Do?

Through a Care Manager, a Children’s Health Home provides:

  • Comprehensive Care Management
  • Care Coordination and Health Promotion
  • Comprehensive Transitional Care
  • Individual and Family Support
  • Referral to Community and Social Support Services

Why should families want to enroll their children in a Health Home?

At Astor Services for Children & Families, we understand caring for your child can be a complicated and often exhausting experience. In response to the needs of the families we serve, we are proud to have joined together with the Children’s Health Home of Upstate New York  (CHHUNY), The Collaborate for Children and Families (CCF),  and Bronx Accountable Healthcare Network (BAHN Health Home, Montefiore Care Management) to provide Care Management Services that put your family first. 
Astor’s Heath Homes Care Coordination program provides Care Management services to children in 9 Hudson Valley Counties (Putnam, Rockland, Dutchess, Orange, Columbia, Sullivan, Greene, Delaware), and The Bronx. 

For more information or to make a referral to this program, contact:
Denise Brown, Health Homes Population Manager at 845-452-2372 x 120 or email at



Targeted Care Management

Targeted Care Management (TCM) is a non-Medicaid care management service provided to children from ages 5 to 21. At this time, children in both Ulster and Dutchess Counties may benefit from this program and must be referred to and approved by their respective county Children’s Single Point of Access (CSPOA) Coordinator.

What does a Targeted Care Manager do?

Care Managers assist children with behavioral health challenges to access and coordinate all of their healthcare and social service needs. Services include:

  • Develop a personal plan to meet one’s physical, mental health, and social service needs.
  • Coordinate, monitor, and evaluate the ongoing effectiveness of the child’s care.
  • Provide follow-up from inpatient and emergency room care to help prevent re-admissions.
  • Assist children and families with access to important resources such as public assistance, housing, childcare, food pantries, transportation, and more.
  • Provide physical and behavioral health education and support for the child, their family members, and other caregivers.
  • Ensure that all providers share vital information to ensure the most safe and effective services.
  • Care managers work to connect with children in their homes and at healthcare, education and social service sites across Dutchess and Ulster Counties. Care Managers reach out to engage children and their families in hospitals and those referred by community agencies, families, schools, health/behavioral health providers, and other social services.

The effectiveness and quality of services provided by our program are monitored by the New York State Office of Mental Health.
For more information or to make a referral to this program, contact:
Deborah Disanza, LCSW-R
Children’s SPOA Coordinator
Dutchess County Dept. of Behavioral & Community Health
230 North Road
Poughkeepsie, NY  12601
Phone (845) 486-2768 Fax (845) 486-2829
Cathy Woyahn, LCSW-R
Child SPOA Coordinator/Children’s System Specialist Ulster County
Department of Mental Health Local Government Unit
239 Golden Hill Lane
Kingston NY 12401
Phone: 845-340-4149
FAX: 845-340-4094


Contact Us:

For more information or to make a referral to this program, contact:

Denise Brown, Health Homes Population Manager
46 Lincoln Avenue
Poughkeepsie, NY 12603
Tel: 845-452-2372 x 120

Learn about Astor's other Hudson Valley Community-based programs: