Health Home is a healthcare delivery approach that focuses on the whole person and provides integrated healthcare coordination that includes primary care and behavioral healthcare. Channel Marker’s Health Home team of professionals includes a Health Educator, a Registered Nurse and a consulting Nurse Practitioner that work together, alongside the Psychiatric Rehabilitation team, to provide comprehensive assessment and coordinated care for adults with a serious mental illness. It is our goal to assist individuals by improving overall wellness by addressing their behavioral, somatic and social needs. Our goal is to provide screening and evaluation, coordinate care with community providers, reduce avoidable hospital usage, increase self-management of chronic illnesses and improve health outcomes for our clients.
Comprehensive Care Management: The Health Home team will be responsible for coordinating primary and behavioral healthcare and social services for the individual. This will include assessment and goal planning in collaboration with the PRP team and the individual and designated support system.
Comprehensive Transitional Care: It is the goal of the Health Home team to provide services that will help reduce emergency room visits and hospital admissions. Participants will learn to manage their care and be proactive instead of reactive. Staff will ensure timely and proper follow up care. Transitional care will vary by age and may include transitions to or from other types of care.
Individual and Family Support Services: Health Home will assist individuals to attain their highest level of health and functioning possible in their community. Identified family members and support systems are an important part of this model of whole person wellness. The Health Home team will act as advocates and provide support however needed.
Care Coordination: Through implementation of client goals, staff will link clients to referrals, coordinate services, and follow up to needed services and supports.
Health Promotion: Health Home staff will provide health education services with a strong emphasis on skills development for monitoring and management of chronic and other somatic health conditions. The team will also reinforce preventative health initiatives.
Referral to Community and Social Support Services: It is a goal of the Health Home team to develop relationships with other health care professionals and agencies within the community, to help join our efforts and improve client access to care.
Clients can meet with staff individually or in group settings at one of our three facilities in Easton, Denton, or Cambridge or in community settings.
Health Home staff hours vary on days and site locations and coincide with the hours of the day programs that are open Monday through Fridays from 8am – 4pm.
Clients must be enrolled in Channel Marker’s Psychiatric Rehabilitation services and meet medical necessity requirements for PRP.
Clients must be in therapy for mental health treatment.
Clients must be enrolled in Medicaid