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URMC / Transitional Care Medicine / Services & Programs / Health Home & Care Management


Health Home & Care Management

Care Management team

What is a "Health Home?"

A Health Home is a care management service model whereby an individual's caregivers communicate with one another so that the patient's needs are addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to the services an individual 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."

The goal of the Health Home program is to make sure its members get the care and services needed. This may mean fewer trips to the emergency room or, less time spent in the hospital. It could mean getting regular care and services from doctors and providers. Or, finding a safe place to live, and a way to get to medical appointments.

How Can I Enroll?

You can talk to your current service provider or you can contact a Health Home at any time to find out if you are eligible to enroll. You also may be referred to a Health Home by Medicaid, based on care and services you have already received. Or, you can be referred by your Managed Care plan, doctor, specialist, hospital emergency room or discharge planner, or Social Service District.

Contact Information

The Complex Care Center is a Health Home Provider through the Greater Rochester Health Home Network.

For more information, call (585) 276-7900 or email

Care Coordination

The Complex Care Center has partnered with Person-Centered Services and Prime Care Coordination to integrate Care Coordinators into our practice. For more information please refer to our CCO program brochure.