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Community Care

NYC Health + Hospitals/Community Care reaches outside of the walls of our hospitals and clinics to ensure that our patients access the highest quality of care and support they need when returning to the community. We offer expert services to patients residing in Manhattan, Queens, Brooklyn and the Bronx.

Our services include:

  • Home Care, our Certified Home Health Agency (CHHA) provides community-based clinical services, usually after a hospital stay, including:
    • Nursing
    • Physical therapy
    • Occupational therapy
    • Clinical social work
  • Community Care Coordination:
    • Health Home, (for adult patients) our care coordination service that provides assessments, care planning and social support linkages for the chronically ill who may experience challenges with food insecurity, financial support, homelessness and 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.
  • Health Home Plus (HH+) is an intensive Health Home Care Management (HHCM) service established for defined populations diagnosed with HIV/AIDS or Serious Mental Illness (SMI) that are enrolled in the Health Home Program. In order to ensure their intensive needs are met, Health Home Plus members are served at a higher level of intensity which includes a minimum of 4 core services monthly 2 of which are face to face.

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:

Maternal-Child Health

Our Maternal-Child Health program helps new and expecting parents and their infants stay healthy before and after birth. Our program helps families with:

  • Breastfeeding techniques and support
  • Parenting and child-care skills for the growing family
  • Postnatal care for parent and infant
  • Specialized services for babies born with abnormalities who require additional care
  • Specialized care of the chronically ill child from birth to 17 years old
  • Specialized care for parents who continue to experience postpartum 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.