How to make a referral to Hudson Valley Care
For providers and hospitals who would like to refer a member for health home services, please complete our referral form and send to:
Please see below steps in making the referral to HVC.
Health Home Criteria
Make a clinically informed, presumptive assessment about eligibility:
Step 1: Ensure the patient is eligible for Medicaid and the Medicaid is active
Step 2: Assess Diagnostic Eligibility
- At least TWO chronic conditions including, but not limited to: mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI>25 or other chronic conditions. Full list of conditions. OR
- HIV/AIDS; OR
- A Serious Mental Illness
Step 3: Assess Health Home Appropriateness
The person has significant behavioral, medical, or social risk factors and can benefit from comprehensive care management services:
- Inadequate connectivity to the healthcare system for example no primary care provider, no connection to specialty doctor, does not keep appointments, etc.
- Non-adherence to treatment/medications or difficulty managing medications
- Inappropriate ED use
- Repeated hospitalizations for preventable conditions either medical or psychiatric
- Recent release from incarceration
- Deficits in activities of daily living such as dressing & eating
- Lack of or inadequate social/family/housing support (including homelessness) or serious disruptions in family relationship
Once HVC is in receipt of the referral and determines the member is appropriate for health home services, the member will be assigned to one of our care management agencies who will contact the member for engagement in health home services.