Health Home Care Management

Care Managers work with adults, children and their families who enroll in a health home to develop an individualized plan of care, and then help them navigate the health care delivery system, schedule appointments, arrange transportation and communicate between health care providers.

How can the Care Manager help me/my child?

  • Coordinating care through effective communication with other providers
  • Advocating on your/your child’s behalf
  • Navigating the complex healthcare system
  • Providing linkages to resources for finding affordable housing, food, clothing, childcare, transportation, etc.
  • Identifying your/your child’s goals and ensuring everyone involved in your/your child’s care understands the goals and the care plan

Who is eligible?

  • Medicaid recipients, including those who are already members of a Managed Care Organization. Individuals who have both Medicaid and Medicare are also eligible.
  • Orleans County resident.
  • Those eligible need to meet one of the following conditions:
    • Two or more chronic health conditions, such as asthma, diabetes, heart disease, mental health condition or substance use disorder, or
    • A significant Mental Illness, or
    • Living with HIV/AIDs

How to make a referral?

Orleans County accepts referrals from the community (health care providers, community organizations, individuals and/or family members) for enrollment of eligible individuals into the Health Home Care Management Program.

There are two ways to submit a Child or Adult Care Management Referral:

1. Orleans County SPOA
Please complete and return the appropriate Orleans County SPOA Application to Alyssa Thomas, Orleans County SPOA Coordinator, via fax at (585) 589-6395:
2. On-line

For further information about Care Management services, please contact:

For Youth Care Management Inquires / Information, Please Contact:
Alan Girangaya (585) 589-2861 or Karen Krug (585) 589-2788

For Adult Care Management Inquires /Information, Please Contact:
Darcy Kaminski (585) 589-3259