How We Care For You
Community Care provides high quality, personalized community-based services for individuals who need special care and support after a hospital stay or help with managing a chronic health condition in the community.
Our services include:
- Community Care Coordination:
Health Home, (for adult patients) our care coordination service which provides assessments, care planning, and social support linkages for the chronically-ill who may experience challenges with food insecurity, financial support, homelessness, non-emergency medical transportation among other needs. Click here to learn more about Health Home.
- Behavioral Health, our care coordination program assisting eligible patients with chronic behavioral health conditions to access specialized health plan benefits including home and community-based services.
- Complex Care, our joint home care and care coordination service for patients with multiple chronic health conditions who require social service support systems residing in homeless shelters or the specialized clinic at NYC Health + Hospitals/Bellevue.
- Community Care Management
- Care Transitions, our specialized nurse-led telephonic care coordination program supports the safe discharge of chronically-ill patients from our hospitals and back to their communities with connections to home care, primary care and social support services.
Specialized Community Care Programs
In addition to expert home care services, we offer specialized clinical programs to help keep our patients healthy in the home setting:
Our Maternal-Child Health program helps new and expecting moms and their infants stay healthy before and after birth. Our program helps moms and families with:
- Breastfeeding techniques and support
- Parenting and child-care skills for the growing family
- Postnatal care for mom and infant
- Specialized services for babies born with abnormalities who require additional care
- Specialized care for moms who continue to experience post-partum complications
To learn more about our specialized programs, call 1-866-692-HOME (4663).
Refer to Community Care
We welcome referrals from our partners in health care as well as patients and their families living in Manhattan, Brooklyn, Queens and the Bronx. Call us at 1-866-692-HOME (4663) to make a referral or learn more about Community Care services.