Our History

The New York State Care Coordination Organization/Health Homes (CCO/ HHs) were designed by NYS Office for People With Developmental Disabilities (OPWDD) and NYS Department of Health (DOH) to replace the Medicaid Service Coordination (MSC) model to enable a more comprehensive, integrated, and holistic service coordination to better support people, with complex health care needs.

The goal and focus of CCO/HHs and their Care Managers are to improve care and health outcomes, lower Medicaid costs, and reduce preventable hospitalizations, emergency room visits, and unnecessary care for Medicaid members. This is in stark contrast to former Medicaid Service Coordination (MSC) provider agencies.

Supporting People with Complex Needs

The CCO/HH Care Managers are essential resources and advocates to New York’s high-risk and vulnerable population. Health care and clinical staff/teams support the CCO/HH Care Managers to assess and align disability supports and services based upon a comprehensive person-centered assessment and Life Plan for each individual. CC/HH Care Managers coordinate medical; home and community-based services; and other community resources for individuals with I/DD needed and desired to live a quality life.

“The heart of a Care Manager has persistence, compassion, and curiosity to keep on going and to advocate for the best possible outcome.”

Timeline

March 2014

A federal rule required that “Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management or develop the person-centered service plan.” The federal rule ensured conflict-free case management with services reflecting recipients’ interests and not those of the provider agencies.

April 2018

The New York State Department of Health (DOH) and the New York State Office for People with Developmental Disabilities (OPWDD) received approval from the Centers for Medicare and Medicaid Services (CMS) to expand the Health Home Care Management program to serve Individuals with Intellectual and/or Developmental Disabilities (I/DD) through specialized I/DD Care Coordination Organization/Health Homes (CCO/HHs).

July 2018

Provider agencies from over 350 I/DD agencies across New York partnered and invested in creating the seven (7) Care Coordination Organization/Health Homes (CCO/HHs) to meet the July 1, 2018 implementation date. Each CCO/HH made significant investments in resources to launch the new organizations. The provider agencies’ “Medicaid Service Coordinators” (MSC) were hired to fill the new, “Care Manager” positions and were provided with comprehensive and ongoing training and education to meet the expectations of their new roles. 108,000 individuals with I/DD opted into this new, comprehensive model of Care Management. This transition ensured the provision of conflict-free care coordination with the goal to improve access to services, improve care coordination of services and improved health outcomes.

Today

In only 2 years, CCOs have developed and implemented a comprehensive, holistic, and integrated care coordination infrastructure to serve 108,000 individuals with I/DD and their families.

Innovations include the following:

A Health Information Technology infrastructure was developed and deployed by CCO/HH to support the Health Home mission.
Integrated and comprehensive care coordination system with external data sources to provide Care Managers the best tools and most up to date information to provide care support networks for those that need it most.
Regional Health Information Organizations (RHIO) data enabling Care Managers to respond timely to ER visits and hospitalizations and to ensure members are connected to the services and providers they need. CCO/HH are connected to hospitalization information enabling timely and safe transitions of care.
CCOs have the technology and analytical tools to aggregate data from various sources to analyze and identify opportunities for population health improvement, implement quality enhancements, and target service gaps.
The CCOs meet strong information security standards set by NYSDOH, this includes compliance with hundreds of security controls and annual audits to ensure the information of the people we support is protected.

CCO/HH Care Manager Role

Work with individuals with I/DD and their families to create individually tailored Life Plans that include I/DD services, health and behavioral health services, social and community supports to live well-rounded and fulfilling lives.
Serve as a lifeline and advocate for individuals and their extended families assisting with critical tasks such as access to and maintenance of Medicaid and other benefits, access to housing, respite, recreation, medical, dental and behavioral health supports, and crisis services.
Assist individual/families in navigating systems such as social services, medical institutions, psychiatric placements, schools/education systems, shelters, jails, ACCES-VR, etc.
For many individuals without family and natural supports, CCO/HH Care Managers provide a safety net, checking in on them regularly and ensuring access to supports/services including housing, food, medical care, medication, and transportation.