Health Home


What is Health Home?

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 Registered Nurse and a consulting Nurse Practitioner that work together, alongside the program staff, 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.  


How Does Health Home Provide Assistance?

Comprehensive Care Management 

The Health Home team is responsible for coordinating primary and behavioral healthcare and social services for the individual. This includes assessment and goal planning in collaboration with the program staff, the individual, and designated support system.

Comprehensive Transitional Care

It is the goal of the Health Home team to provide services that help reduce emergency room visits and hospital admissions. Participants will learn to manage their care and be proactive instead of reactive. Staff help ensure timely and proper follow-up care. Transitional care varies by age and may include transitions to or from other types of care. 

Individual and Family Support Services

Health Home services support individuals to attain the 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 acts as advocates and provide wellness support, however needed. 



Care Coordination: Through implementation of client goals, staff help link clients to referrals, coordinate services, and follow-up needed with services and supports.

Health Promotion: Health Home staff provides health education services with a strong emphasis on skills development for monitoring and management of chronic and other somatic health conditions. The team also reinforces 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. 


Where and When Does Channel Marker Provide Services?

Clients can meet with staff individually or in group settings at one of our three program centers located 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 program centers that are open Monday - Fridays from 

8am – 4pm.

Client Eligibility - Clients must be enrolled in Channel Marker’s psychiatric rehabilitation services and meet medical necessity requirements for services. Clients must be enrolled in Medicaid and receiving mental health treatment and therapy.