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In today’s society, the health care system touches the lives of children more than ever before.  Due to unfortunate situations like the current opioid crisis in our country, our children are struggling physically and emotionally.  These traumatic events can often represent as serious physical, mental and behavioral problems for children of all ages.  Parents and caregivers are struggling to face these behavioral and health concerns head on.

But finding the proper services for their children and family can leave them bewildered, and some are not aware services even exist to help them.  If they are lucky enough to find an organization that provides appropriate services for their child, it can be very frustrating to spend countless hours being transferred from department to department trying to get critical answers and information regarding their child’s services, sometime with no answers, or other times finding out you will need multiple agencies and providers to address your child’s needs.  Working with several agencies at one time means working with each Agency’s specific treatment plan, often resulting in disjointed care.

This approach has proved to be overwhelming and hopeless at times, to families and children alike, but this can now be a struggle of the past.

The Health HomeModel

In November 2010, the American Public Health Association (APHA) endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals by increasing access to care, reducing health disparities, and better integrating health care with public health systems. The Affordable Care Act allowed states to redesign initiatives to integrate physical and behavioral health care, and transition benefits that had previously been carved out of managed care. In an effort to cut waste and improve outcomes, New York State petitioned the federal government to allow the state to make changes. 

The result was Health Homes, a more systematic, synergistic and trauma-informed approach to providing services between all varieties of providers and populations.

In 2016, KidsPeace partnered with Children’s Health Homes of Upstate NY (CHHUNY) to provide case management services to qualifying children and families across New York State. Serving 54 of the state’s 61 counties, CHHUNY’s expansive network allows families flexibility and continuity of services no matter where in the state they currently reside, or choose to move. KidsPeace currently serves approximately 50 children across the state, and we are steadily growing.

Health Homesis a care management service model where all caregivers and service providers can focus collaboratively on one set of goals to address the family/child’s needs.  Once it is determined that a child meets eligibility requirements, a Health Homes Care Manger completes Strengths and Needs, Safety and Crisis, Emergency and Comprehensive Assessments on the child and the family to determine where to start providing care. From there our Care Managers can help the family by identifying and linking the family to available community support services based on family-driven input into their treatment plan. 

Core Services and Components

The five Core Services provided through Health Homesinclude individual and family support, referrals to community and social support services, comprehensive care management, care coordination and collaboration to promote health and transitional care for clients.  Based on published evidence, eight components to this model have emerged:

  • Patient engagement
  • Caregiver engagement
  • Complexity and medication management
  • Patient education
  • Caregiver education,
  • Patients’ and caregivers’ well-being
  • Care continuity
  • Accountability (1)

All are essential to providing high-quality patient care, reducing avoidable readmissions and recidivism, and improving outcomes.

Care coordination

Care coordination is about making sure the simple things are done in order to avoid more serious issues. Care managers can call and prompt a family when a preventative appointment needs to be made, or call and make to appointment for the family if the family prefers.  They can find and introduce families to helpful services they did not know existed, assist with filling out paperwork, or setting up transportation like Medicaid’s cab payment program.  Care managers can communicate with other service providers if the family is overwhelmed, and ensure a single consistent focus and set of goals.  Care management can be as simple as a phone call to see how someone is doing, accompanying them to the doctor or a human resources agency, or helping them obtain a MetroCard so they have the ability to get to medical or behavioral health appointments.  Care managers are advocates on the family’s behalf and their best interest, which is essential when the provider’s and families’ perspectives do not align, or when communication between service providers needs to improve to ensure continuity of care.  These simple services can make a world of difference and gives clients and their families the means to feel comfortable requesting help.

Health Home Care Managers work independently for the families. They strive to learn their individualized needs and work closely with them to make the most appropriate decisions. They simultaneously work with each service provider to ensure they work collaboratively in the best interest of the child. Care managers closely monitor information on each service the child is receiving, enabling them to keep parents informed and eliminating redundancy of service.   Strengths and Needs Assessments are conducted every six months to assess progress.  All aspects of care are documented in an Electronic Health Record.  Progression of the attainment of goals drives the treatment plans.  Treatment plans are shared with all providers, and since the whole process is voluntary, nothing happens without the family’s consent. Health Homes’ more trauma-informed approach to managed care helps to ensure each child is linked to the best suited providers, as well as monitor that each child is receiving preventative medical and dental care to be able to detect any abnormalities early on.


As with all programs, there are some challenges. Care managers need data so they can know when one of their patients ends up in an emergency room, or to know if a prescription is filled on time.  If a patient is hospitalized, the care managers need to make sure they are involved in the discharge planning, to make sure there are adequate social supports in place when the client returns home. Better data and Interfacing of systems would make it easier.  Some clients are untrusting of the system, and establishing a relationship with individual families and community programs personnel is essential to the success of the program and essentially the success of each individual client. 

The Health Homesprogram believes every family has strengths and they are the most effective drivers of their own care. Health Homeswants to expand and improve each family’s strengths, so eventually they will learn to navigate the system without outside interventions – to function successfully independently, and advocate for themselves. 


  1. J Am Geriatr Soc.2017 Jun;65(6):1119-1125. [Abstract] Components of Comprehensive and Effective Transitional Care retrieved from
Marnie Roberts, LMSW

Marnie Roberts, LMSW

Marnie Roberts, LMSW, is the New York State Manager of Foster Care and Community Programs. She has been with KidsPeace 29 years, 16 of which involved development of new Foster Care programming across several states.