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Welcome to the Medicaid Health Home HIV/AIDS Care Management Website! 

Who are We?


Health Home HIV Care Management providers began in 1990 as the Community Follow-up Program (COBRA Case Management).  Agencies participating in the Community Follow-up Program provided comprehensive case management services targeted to intensive need Medicaid eligible HIV+ persons and their families.  As of January 2012, this program has been transitioning to provide care management in a Health Home for Medicaid recipients with HIV disease and/or eligible chronic conditions.

  A Health Home is a network of health care and service providers targeting the least engaged, highest need clients with complex conditions. The Health Home network includes hospitals, managed care plans, clinics, mental health and substance use services, and community-based services such as care management, housing, nutrition, and other social services. Medicaid eligible persons with HIV/AIDS, or one serious mental illness, or two chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI over 25, or other chronic condition) are eligible for Health Home enrollment. Enrollees should also have significant behavioral, medical or social risk factors which can be ameliorated through care management. Individuals can be enrolled by self or agency referral , or may be referred by the state based on their history of hospitalization and emergency room use.

Each Health Home member is assigned a care manager who assesses their needs and assists them to access and coordinate services. The goal is to provide better integrated, coordinated services with good communication, contributing to higher quality, less costly care and improved health.



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