The FSNNY Inc. Children’s Health Home (CHH) Program is a Care Management program that is designed to “provide comprehensive, integrated physical and behavioral health care that recognizes the unique needs of children and their families”. We are a holistic program with a goal to work collaboratively with youth/families and the various service providers’ (i.e. medical doctors, school based support teams, dentists, mental health service providers, recreational/vocational programs, etc.),  that services them within their communities.

OUR SERVICES

The CHH services youth between the ages of 0 and 21 who are at risk for an adverse event such as:

• Hospitalization, an out of home placement, etc.

• Inadequate social/family/housing support or who may have experienced serious disruptions in their family relationships.

• Poor connectivity with the healthcare system and who may not be adhering  to needed treatment.

• Youth who may have recently returned to their homes after  incarceration, placement, detention, or psychiatric hospitalization.

• And youth who have deficits in activities of daily living, learning or cognition issues.

The CHH program provides care coordination and planning that is “Family-and-Youth driven” and provides a system of support and care that builds on and fortifies the strengths of youth and their families.

ELIGIBILITY

Youth are eligible to be enrolled in CHH if they have Medicaid and are suffering from impaired functioning as a result of being:

1. Diagnosed with 2 chronic conditions such as:

   1. Metabolic Disease (e.g., Diabetes)

   2. Respiratory Disease (e.g., Asthma)

   3. Cardiovascular Disease (e.g. Congenital heart disease)

   4. Obesity (BMI above the 85th percentile)

   5. Alcohol and/or  Substance Abuse

   6. Other Chronic Conditions

OR

1.  Has 1 of the following single qualifying chronic conditions:

   1. HIV/AIDS

OR

1. Serious Emotional Disturbance Diagnosis (as listed below):

1. Schizophrenia Spectrum and Other Psychotic Disorders

2. Bipolar and Related Disorders

• Depressive Disorders

1. Anxiety Disorders

2. Obsessive-Compulsive and Related Disorders

3. Trauma-and Stressor-Related Disorders

• Dissociative Disorders

• Somatic Symptom and Related Disorders

1. Feeding and Eating Disorders

2. Disruptive, Impulse-Control, and Conduct Disorders

3. Personality Disorders

• Gender Dysphoria

• Paraphilic Disorders

• ADHD (with specific criteria):

  1. The youth is taking psychotropic medication AND has utilized at least one of the following services in the past three years:

  • Psychiatric Hospitalization

  • Placement in a Residential Treatment Facility

  • Attended a Day treatment program

  • Placement in a Community residence

  • Received HCBS Waiver services

  • Received Targeted Case Management Services

OR

1. Has a history of Complex Trauma

The CHH program provides six core services to our youth and their families in order to promote family unity and optimal functioning within the community:

1. Comprehensive Care Management

• Completing a comprehensive assessment; completing a person centered, family-focused, plan of care with the child and family; Consulting with a multidisciplinary team on the child’s needs and goal; Conducting clinic outreach and engagement activities to assess on-going and emerging needs and to promote continuity of care and improved health outcomes; Preparing crisis intervention plans; etc.

2. Care Coordination and Health Promotion

• Coordinate with service providers and health plans to secure necessary care, share crisis intervention and emergency information; Coordinate with treating clinicians to assure that services are provided and to assure changes in treatment or medical conditions are addressed; Conduct case reviews with the child/family and interdisciplinary team to monitor/evaluate client status/service needs; Crisis intervention;  Advocate for services and assist with scheduling of services; Monitor, support, and accompany the child and family to scheduled medical appointments; etc.

3. Comprehensive Transitional Care

• Follow up with hospitals/ER upon notification of child’s admission and/or discharge to/from an ER, hospital/ residential/rehabilitative setting; Facilitate discharge planning and follow up with hospitals/ER /residential/rehabilitative setting; Link child/family with community supports to ensure that needed services are provided; Follow up post discharge with child and family to ensure needed services are provided; Notify and consult with treating clinicians, including child’s primary care physician, schedule timely follow up appointments, and assure that all ordered medications are in the home and at other administering sites (e.g., schools and day care), assist with medication reconciliation; etc.

4. Patient and Family Support

• Develop, review, revise child’s plan of care with child and family to ensure plan reflects child/family’s preferences, education, and support for self-management; Consult with child/family/caretaker on advanced directives and educate on client rights and health care issues as needed; Meet with child and family, inviting any other providers to facilitate needed interpretation services; Refer child and family to peer supports, support groups, social services, entitlement programs as needed; etc.

5. Referral to Community Supports

• Identify resources and link child/family to community supports as needed; Collaborate and coordinate with community based providers to support effective utilization of services based on child/family need; etc.

6. Use of Health Information Technology (HIT) to Link Services

“The struggle you’re in today is developing the strength you need for tomorrow. Don’t give up.”
- Robert Tew