Health Home Care Coordination

Harmonia Health Home Care coordinators are dedicated to helping patients stay healthy and out of the hospital or emergency room. Available to Medicaid recipients 21 years of age and older who have Mental Health concerns and two or more chronic conditions, we will coordinate and provide you with access to care available in the community.


In order to be eligible for Health Home Services an individual must be enrolled in Medicaid and experience:    

Two or more chronic health conditions, such as asthma, diabetes, heart disease, mental health or substance use disorder.

In addition, one or more of the following risk factors must exist:

  • Homelessness or risk of homelessness
  • Lack of social or family support
  • Non-adherence to treatments
  • Learning or cognitive issues
  • Deficits in activities of daily living


  • One single qualifying chronic condition: HIV/AIDS
  • Serious Mental Illness (SMI)


What You Can Expect

Our Health Home Care coordinators are person centered. We advocate for the needs of the individuals we serve, focusing care on the individual’s basic needs, individual preferences and values. This is done by sitting down and creating a care plan that is focused on your needs. 

Our care coordinators serve all of Erie County and will come to your house or meet you somewhere you are comfortable. 

Your care coordinator will link you to providers in the community including medical doctors, dentists, cardiologists, pain management and inpatient or outpatient mental health or substance abuse programs. We make sure your doctors are communicating with each other and with you so don’t have to feel overwhelmed. Care coordinators will assist you with finding alternative methods of transportation to get to your appointments. 

Your care coordinator is not limited to these services only. They have a wide range of knowledge and can help you find other services that fit your needs. Once you're enrolled, you will gain all these services at no cost to you. 

Having financial problems? Care mangers help with the process of applying for benefits through the Department of Social Services for SNAP, Cash Assistance, HEAP, air conditioning programs and weatherization. 

Thinking about going back to college or need to get your GED? Your care coordinator can help you apply for financial aid and job training services and assist you with getting your GED.