Care Coordination

Health Home

Health Home is a program within Aging & Long Term Care that empowers individuals to take charge of their own health care through person-centered health action planning. Care Coordinators work with participants to establish health-related goals, increase their confidence and skills to manage these goals, access health care services, and much more.

Who is Eligible?

People on Apple Health (not offered if on a Medicare Advantage Plan) who have one chronic condition and are at risk for one or more additional chronic conditions.

Call us if you want to learn more about this program! There’s no additional cost for this service and participation is voluntary.

If you decide to participate, the care coordinator will help you…

• Identify your health care goal
• Identify the services and resources necessary to reach your goal
• Coordinate and support ongoing communications between providers

This list is not all inclusive, and this program offers much more support. For more information, please give us a call.

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Client Success Stories

*The names in these stories have been changed to protect the privacy of our clients. 

• Alina is a 35-year-old female who suffers with Anxiety, Depression, Chronic pain, PTSD and history of abuse. Her Care Coordinator supports her through a variety of challenges, including learning proper use of the medical system, acquiring greater skills in communicating with providers and specialists, navigating shelters during a period of homelessness, navigating pain management, and achieving stability in the home. Alina is now working part-time at an assisted living facility. Her home and family life are going well, and she is preparing to move to a larger apartment to accommodate her growing daughter. Alina no longer visits the ER as frequently and has achieved a stable income, stable mental health, and a stable home for her daughter.
• Adil is a 66-year-old Arab male who does not speak English and needs an interpreter. Adil and his care coordinator have been working together for 8 months. Since working together, Adil shared that he is better able to get his health concerns addressed in a timely manner. His care coordinator helps him advocate for specialized care needs such as pain specialists, imaging, food benefits, and more. Adil is hopeful that with the continued help of the Health Home Program, he will have his pain adequately addressed so that he can continue his passion for making children laugh through magic shows.

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How Do I Apply for Services?

If you are interested in applying for services, Aging & Long Term Care staff can assist you with an online application. To find out more about the program or to enroll, call our Community Living Connections program at 509-960-7281.