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Health Home

    Our Bronx Health Home Model utilizes a multi-disciplinary team, to provide care management, clinical care, and social support services to all enrollees. The Health Home team includes care coordinators, primary care physicians, behavioral health providers, LCSWs, clinicians, and social service supporters (i.e. outreach workers, health educators). This team works with an integrated model of service that includes BLHC as the primary medical institution for enrollees. Several other local medical, behavioral health, and social service community-based organizations also work to support members of the program. All enrollees are evaluated by a Care Coordinator, under the appropriate supervision, who conducts a comprehensive needs and resources assessment to identify medical, mental, chemical dependency, and social service needs. The Care Coordinator, with the help of his/her team, then develops a plan of care that addresses the identified needs by referring and linking members to community-based networks, providing instruction, and other effective methods. All referrals are actively tracked and managed by the care coordinator per the level of need of the individual member.