Home Health Care Management

In order to help children, adults, and families get the most out of a complex healthcare system, Northern Rivers provides comprehensive Care Management services to Medicaid participants enrolled a Health Home. Care Management ensures that every client has both “voice and choice” when navigating the complex behavioral and physical healthcare system.

Each client receives personalized planning, community support and services coordination designed to improve health and overall wellbeing. These services are free, voluntary, and specially designed to assist and provide support to children, adults, and families managing chronic and/or acute medical and behavioral health concerns.

Available Services

  • Comprehensive care management
  • Care coordination and health promotion
  • Comprehensive transitional care
  • Individual and family support
  • Referral to community and social support services
  • Health information technology


  • Presence in 23 upstate counties that ensures continuity of care for a child, adult, or family who moves residences
  • Standardized processes that provides ease of access to Local Departments of Social Services (LDSS) and community referrers
  • Proven understanding of the unique needs of children and families
  • Commitment to family-driven care (our model proposes coaching the family to manage their own care)
  • Commitment to principles of Family Finding for disconnected youth
  • Access to systemwide consultation for assistance with complex needs

Children’s Health Home Care Management services are available to children from birth up to the child’s 21st birthday who are or will be Medicaid eligible, reside in Albany, Clinton, Columbia, Essex, Delaware, Franklin, Fulton, Greene, Hamilton, Herkimer, Montgomery, Otsego, Rensselaer, Saratoga, St. Lawrence, Schenectady, Schoharie, Ulster, Warren, and Washington counties and the St. Regis Mohawk Reservation.

Adult Health Home Care Management are available to adults who are experiencing two or more chronic conditions, or HIV, or have a mental health concern, including severe emotional disturbance (SED) or are seriously and persistently mentally ill (SPMI).