About Us

The AHI Health Home initiative began in 2012.

As a lead Health Home, AHI tries to remove as many barriers as possible so care managers can spend their time doing what they do best: providing compassionate and effective care management.


The AHI Health Home operates in eight Adirondack/North Country counties…some of the most rural counties in New York:

  • Clinton, Essex, Franklin, Hamilton, St. Lawrence, Warren, Washington, and parts of Saratoga county.

These counties populate a land mass that is about 24 times larger than New York City’s five boroughs, with a population that is 1/28th the size. A small population spread across a large region can lead to a tremendous number of geographic challenges and scarcity of services.


The AHI Health Home encourages collaboration across agencies as much as possible. Our Health Home service providers share resources and best practices with one another. Given our rural geography, this coordination and collaboration is especially critical in ensuring excellent care management.

AHI Health Home Enrollment and Outreach is growing!

As of January 2014 As of January 2015 As of January 2016
Enrollment: 822 1,693 2,109
Outreach: 193 1,084 1,075

How the AHI Health Home Works

Individuals are referred to the AHI Health Home in one of three ways:

  • Assigned by the New York State Department of Health (NYS DOH);
  • Referral by the agency providing care;
  • Self-referral or referral from an outside agency.

Care managers attempt to locate prospective AHI Health Home clients, inform them about Health Home, assess whether they meet the criteria for the program, and enroll them if the individual qualifies and is interested.

Once an individual is enrolled, they are considered Health Home members and assigned a care manager who will work with them to ensure they are receiving all needed services to be as healthy as possible.

Care managers coordinate services with and for Health Home clients at least once monthly.

Prospective Health Home clients can be resistant to engaging in care management. They may distrust a health care system that has historically failed them. Care managers work hard to engage people, mitigate suspicions and earn individual trust. AHI Health Home Success Stories are a great testament to care managers.

AHI’s Role

The AHI Health Home coordinates referrals, hosts regular meetings for partner care management agencies to review NYS DOH policies and procedures, identifies areas for improvement, and shares best practices.


The AHI Health Home program is funded by Medicaid and Medicaid Managed Care. AHI Health Home participants do not pay out-of-pocket for this service.

“The best part of Health Home is that you know that your care manager will call you to check on you and keep you motivated.

– Health Home client

More Information

Contact us to learn more about the AHI Health Home.

Tell others about Health Home!

Share the AHI Health Home Brochure.
Share the AHI Health Home Serving Children Brochure.