At Hudson Valley Care Coalition (HVCC), we believe improving health isn’t just about treating illness, it’s about looking at the whole person. That means addressing mental health, chronic conditions, as well as housing support, nutrition, and transportation, all of which play a critical role in overall well-being.
For more than a decade, HVCC has served as a Health Home lead entity for the Hudson Valley, working with Medicaid members with complex health needs. Through coordinated care and strong partnerships, we’ve seen the benefits of a whole-person approach to improving health outcomes.
Proven Results from Health Home Care Coordination
Our Health Home Care Management program has shown measurable improvements in both health outcomes and quality of life. As demonstrated in our most recent impact report of more than 5,000 Health Home program enrollees, here’s a snapshot of how things have changed for our members:
- Emergency Department (ED) Visits: On average, members came to the ED 2.5 times per year at enrollment. After one year, that dropped to 0.12 — a 95% reduction, saving an estimated $334,878 annually.
- Inpatient Admissions: Within one year of enrollment, average admissions fell by 19%, from 0.76 per year to 0.61, saving an estimated $3.28 million annually.
- Housing Stability: Homelessness decreased by 47%, from 17% at enrollment to just over 5% after one year.
- Incarceration: The percentage of members reporting incarceration in the past year fell from nearly 9% to just 1.36%, a 40% decrease.
- HIV/AIDS Outcomes: Viral suppression improved by 47%, and the percentage of members with critically low T-cell counts dropped by 42% after one year of continuous enrollment.
From Health Home to Social Care Network: Expanding Access
While the Health Home program focuses on members with chronic and complex health conditions, many Medicaid members who aren’t eligible for this care are slipping through the cracks, struggling to stay healthy and safe.
We know that social factors—like food insecurity, unstable housing, and lack of transportation— contribute up to 80% of an individual’s health and wellbeing. These health-related social needs affect a much wider group of Medicaid members — many of whom are ineligible for Health Home care management services.
The Social Care Network changes that.
Launched under New York’s 1115 Medicaid Waiver, the SCN builds on HVCC’s proven coordinated care model and makes it available to more Medicaid Managed Care members with unmet health-related social needs. Now, even members who aren’t eligible for Health Home can access the same level of care.
This means:
- More people can get help with housing support, utility assistance, and safe housing modifications.
- More members can access fresh food, medically tailored meals, and nutrition support.
- More communities can benefit from reliable transportation to non-medical services and critical daily living commitments, like job interviews.
Why This Matters Now
The data from HVCC’s Health Home program proves that coordinated social and clinical care works. The Social Care Network allows us to adapt this approach and reach far more people, addressing social needs early before they become health crises.
Join Us
If you are a healthcare provider, behavioral health organization, or community-based service in the Hudson Valley, we invite you to be part of this next chapter. Together, we can help more neighbors stay healthy, stable, and connected.
