Need support, need to talk? Call 1-800-243-7692
GMHC - Fight Aids. Love Life.

Care Coordination

GMHC’s Coordinated Care Department offers a few care management options to help you navigate your own healthcare. At the center of our care management programs are a group of compassionate and knowledgeable team of care managers, ready to help you find the resources and information you may need, to get the help that you want. Our Health Homes Care Management teams will help you get connected to lifesaving services, find the right substance use and mental health program for you, find out if you are eligible for certain entitlements, advocate on your behalf to obtain entitlements, find housing resources to get you into stable housing, connect you to legal resources, and help you enroll in supportive services with people just like you, in an accepting and judgment-free setting.

Please review our care management program descriptions and eligibility criteria listed below.

Health Home Care Management

The Affordable Care Act of 2010 has created an optional Medicaid State Plan benefit for States to establish Health Homes to coordinate care for people with Medicaid who have chronic health conditions. Health Home Care Management providers operate under a "whole-person" philosophy. Health Homes Care Management integrates and coordinates all primary, acute, behavioral health, long-term care services and, social supports to treat the whole person.

Health Home comprises six services that Medicaid programs can provide to eligible beneficiaries:

  • Comprehensive care management;
  • Care coordination and health promotion;
  • Comprehensive transitional care/follow-up;
  • Patient and family support;
  • Referral to community and social support services; and
  • Use of health information technology (HIT) to link services, if applicable.

Health Homes are for people with Medicaid who:

  • Have 2 or more chronic conditions
  • Have one chronic condition and are at risk for a second
  • Have one serious and persistent mental health condition

Chronic conditions listed in the statute include mental health, substance abuse, asthma, diabetes, heart disease and being overweight. Additional chronic conditions, such as HIV/AIDS, may be considered by CMS for approval.

Transitional Care Coordination (TCC)

The Transitional Care Coordination (TCC) program is a time-limited case management program. The goal of the TCC program is to improve care for people with HIV who are homeless or unstably housed. TCC connects them to primary medical care, housing services, and other social support services. We ensure entry into, and continuity in, HIV primary medical care, providing linkage to housing services, and assisting with access to other community and social support services.


Persons interested in enrollment must meet the following eligibility criteria:

  • Household Income below 435% above of Federal Poverty Level (about $49,985 for a household of one)
  • Reside in New York eligible metropolitan area (NYC, and Rockland, Putnam and Westchester Counties)
  • Be at least 18 years of age
  • Be HIV positive
  • Experience homelessness or be unstably housed
  • Have one or more of the following additional complicating factors:
    • Are newly diagnosed with HIV;
    • Were lost to care (i.e. no primary care visit in the past 9 months or ever in NYC);
    • Have difficulty adhering to ART, to keeping appointments, or receiving sporadic, irregular care.

For more information, please call 212.367.1174 or email