Care Coordination provides integrated health service care for low, moderate to high risk children with health challenges. To qualify, the child must be enrolled in Medicaid and have a documented clinical need.

Medicaid members eligible to be enrolled in a Health Home must have: two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes) or one single qualifying chronic condition, such as HIV/AIDS or a Serious Emotional Disturbance (SED) or Complex Trauma.

Services include: completing comprehensive health risk assessment, formulating care coordination plans, linkages to and for preventive care and appropriate community-based treatment to prevent and avoid unnecessary hospitalizations, ER visits and maintaining community stabilization. Psycho-education is offered to assist members in developing positive habits towards overall good health, wellness, prevention and recovery.

  • Core elements for children’s care coordination include - creating a comprehensive care management plan and using a comprehensive health risk assessment and individualized plan of care to meet the physical, mental health, chemical dependency and social service needs.
  • Care coordination and health promotion - One care manager will ensure that the care plan is followed by coordinating, monitoring and re-evaluating the patient and their care.
  • Comprehensive transitional care - Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up care.
  • Patient and Family Support - Individualized care plan must be shared with patient enrollee and family members and/or other caregivers. Patient and family preferences are considered.

For more information call:

WellLife Network Children & Family Services Tel: 631.920.8302

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