About Health Home Services
Yeled v’Yalda’s Health Home program is designed to organize and manage healthcare needs by building and maintaining a connected network of providers and professionals. Through the Health Home program, Yeled v’Yalda assigns a care manager who provides assistance and support by collaborating with parents to increase access to services and resources, and by helping families develop an all-encompassing and well-organized plan of care. The Health Home program’s goal is to coordinate the full range of healthcare-related matters such as scheduling appointments with providers, organizing transport to and from appointments, maximizing access to available resources, and facilitating effective communication with doctors, hospitals, and other professionals.
Personalized Plan of Care
Yeled v’Yalda assigns a Health Home care manager to meet with children and caregivers in order to develop a comprehensive and personalized plan of care which thoroughly addresses the family’s specific needs and concerns.
Yeled v’Yalda’s Health Home care managers assist in arranging high-quality healthcare services and in scheduling appointments to ensure that children get the care they need in an organized, convenient, and timely manner.
Yeled v’Yalda’s Health Home program focuses on accessing a variety of relevant medical resources and community and governmental support services, to support a healthy lifestyle and enhance quality of life.
Home-Based Community Services (HBCS)/Waiver Services
Health Home care managers arrange for access to crucial services such as HCBS (Home and Community Based Services). HCBS are designed to allow children/youth to participate in developmentally- and culturally-appropriate services through Medicaid. HCBS are intended to provide service options for individuals who would otherwise require care that is provided in a more restrictive environment, such as a long-term care facility or psychiatric inpatient placement, as well as for individuals at risk of requiring that level of care. The array of services offered by HCBS are provided in the home and within the community, and are intended to assist children/youth and families succeed and thrive.
Comprehensive Transitional Care
Yeled v’Yalda’s Health Home program works to facilitate smooth transition between inpatient and outpatient settings, arrange effective discharge planning, and organize appropriate follow-up services.
Yeled v’Yalda’s Health Home program provides ongoing support to children and families through a steadfast commitment to collaboration and partnership.
Yeled v’Yalda’s respite services program focuses on providing necessary short-term assistance to children/youth, and to their caregivers, regardless of developmental, physical, or behavioral disability. Respite services can be provided in a pre-planned mode, or delivered as needed during a crisis situation. Yeled v’Yalda’s dedicated and compassionate respite workers supervise children/youth while engaging them in constructive activities that build and support their interests and abilities. Respite providers are trained and experienced in implementing developmentally appropriate behavioral interventions to support optimal function and behavior for the individuals they work with. Respite workers regularly communicate with caregivers as well as other service providers to promote effective carryover of the skills addressed.
Community Habilitation Services
Yeled v’Yalda’s Community Habilitation program provides direct, community-based services and supports to children/youth, both individually, and in group settings. Yeled v’Yalda’s Community Habilitation services focus on the acquisition, maintenance, and enhancement of the skills necessary to perform Activities of Daily Living (ADLs). Examples of functional ADL skills include goals such as self-care and safety awareness; medication and health management; communication skills; mobility and community transportation skills; community integration and awareness of appropriate social behavior; and problem solving and money management skills.
Caregiver/Family Supports & Services
Yeled v’Yalda’s Caregiver/Family Supports and Services program encourages and promotes the successful functioning of children/youth within the family unit, and enhances the family’s ability to provide care to children/youth within their homes and communities. Yeled v’Yalda recognizes that family units are inclusive and individually-defined, and reflect a broad range of family types and compositions, such as those created through birth, foster care, adoption, or self-created units. Yeled v’Yalda’s Caregiver/Family Supports and Services program promotes interaction and engagement with families and children/youth to offer educational resources, advocacy, and support services, and develops the ability of families and caregivers to independently locate and access community activities and services. Yeled v’Yalda’s Caregiver/Family Supports and Services are provided in person, both individually and in group face-to-face interventions. By collaborating with individuals, families, and caregivers, Yeled v’Yalda’s team of dedicated and experienced support professionals provide an array of community-based opportunities which is outlined in a Caregiver/Family Supports and Services Plan.
Yeled v’Yalda’s prevocational training services help prepare teens and young adults (ages 14+) to engage in paid work, volunteer work, and career planning, and are designed for young adults with disabilities who often cannot successfully access other types of prevocational services. Yeled v’Yalda’s prevocational services are unique in that they are not job-specific, or geared toward teaching the skills required to perform a particular job. Instead, they are intended to facilitate ongoing success in a range of work environments, and are directed at addressing the underlying goals that are necessary to perform optimally in a competitive, integrated employment setting. Prevocational services may include volunteer and internship opportunities, such as learning and training activities, that develop and teach general skills to provide experience and preparation for entry into the paid workforce. Training is provided both in individual and group settings. The goal of Yeled v’Yalda’s prevocational services program is to enable participants to attain work that best reflects their abilities, strengths, and interests, in the most integrated setting possible, and following the applicable federal wage guidelines established by the U.S. Department of Labor. Yeled v’Yalda’s prevocational training focuses on skills such as: * Effective and appropriate communication with supervisors and coworkers; * Ability to follow directions, complete tasks, and problem-solve; * Ability to abide by rules and norms such as punctuality, dress code and workplace conduct; * Travel and mobility training; * Proper use of job-related equipment and general workplace safety; * Career planning, resume writing and interviewing techniques; * Educational planning for future career and vocational goals, and application for financial aid or scholarship opportunities.
Supported Employment Services
Yeled v’Yalda’s supported employment services are individually designed to help prepare teens and young adults (ages 14+) who have disabilities, obtain paid job opportunities and learn to perform successfully and independently in a work setting. Our supported employment services are individualized, and are provided in a variety of one-on-one settings, including actual work sites. Yeled v’Yalda offers a range of services designed to provide intensive ongoing support to help each individual reach their full potential, such as: * Person-centered vocational assessment and employment planning to assess individual interests and appropriate fit for specific job opportunities; * Communication skill-building for interviewing and negotiating with prospective employers; * Job placement, and career development and advancement skills, as well as benefits support and planning; * On-site support such as job coaching, training, and systematic instruction for individuals to learn and acquire specific job skills; * Development of awareness of appropriate workplace behavior to facilitate successful integration into the job setting; * Advocacy with employers with regard to the individual’s disabilities, needs, and related healthcare issues, as well as any adaptive/assistive equipment or necessary accommodations required for employment; * Monitoring progress and providing feedback to support successful performance through on-site observation and communication with job supervisors and employers; * Transportation to and from the work site, and independent transportation skill-building.
Community Self-Advocacy Training & Support
Yeled v’Yalda’s Community Self-Advocacy Training and Support program provides family, caregivers, and collateral contacts with techniques and information to assist them in better responding to the needs of the participant. Community Self-Advocacy Training and Support is intended to assist children/youth with special needs, by helping their caregivers better understand and support their disability-related needs. This service is intended to facilitate participation in community events and integrated interests and occupations, which are important activities for all children and youth, regardless of disability. Yeled v’Yalda provides caregivers with support in these activities, so that they are better able to support the child/youth in their endeavors, and to help prevent problems should they arise. Community Self-Advocacy Training and Support improves the child/youth’s ability to gain from the community experience, as well as the caregiver’s ability to advocate for the child/youth’s disability and health care issues. Yeled v’Yalda’s services are conducted in both individual and group-based face-to-face intervention settings, and provide a range of services intended to support children and caregivers in achieving effectiveness and success in community-based opportunities, such as: * One-on-one or group training for children/youth as well as families and caregivers regarding methods and behaviors which enable success within the community; * Direct self-advocacy training in community settings with collateral contacts regarding the child/youth’s disabilities and needs relating to health care issues; * Self-advocacy training for children/youth as well as families and caregivers, including situations such as community transitions.
The Health Home program requires the following criteria for eligibility:
1. Applicant must be actively enrolled in Medicaid;
2. Applicant must have a diagnosis of two or more chronic health conditions such asthma, diabetes, heart disease; or a single qualifying chronic condition such as HIV/AIDS, Serious Emotional Disturbance (adults), or Complex Trauma (children);
3. Applicant must demonstrate a social/emotional need, such as lack of adequate family or housing support; learning or cognition issues; or recent psychiatric hospitalization.
HOW TO APPLY
At Yeled v’Yalda, we do our absolute best to provide the support necessary to guide families through the process of getting started. To begin, please send an e-mail to our intake coordinator (see sidebar) with the following information:
* First and last name of parent/caregiver;
* First and last name of child being referred;
* Child’s date of birth;
* Child’s diagnosis;
* Medicaid CIN#;
* Parent/caregiver contact information (phone # and email) and preferred method of contact;
* Other Yeled v’Yalda services currently being received;
* Referral source (ie, friend; newspaper ad; family member; Yeled v’Yalda employee).
Yeled v’Yalda’s Health Home program ensures family-centered, cost-effective, and culturally-appropriate services by coordinating and providing access to:
- High-quality healthcare informed by evidence-based clinical practice guidelines;
- Mental health and substance abuse services;
- Comprehensive care management, care coordination, and transitional care between settings;
- Chronic disease management, including self-management support to individuals and their families;
- Individual and family supports, including referrals to community, social, and government services.
The main responsibilities of a Health Home care manager include:
- Coordinating the care and well-being of the families and members they serve by providing the necessary referrals and services;
- Serving as a liaison and central point of contact in order to ensure that families’ needs are met, their choices are valued, and their personal preferences are included in their plan of care;
- Monitoring services to ensure that healthcare goals are being achieved in an effective and timely manner;
- Ensuring that care management services are individualized, family-centered, and community-based.
- An intake specialist will ensure that the child’s Medicaid enrollment is active;
- Eligibility criteria and documents will be collected and reviewed;
- If necessary, referrals for independent evaluations will be made;
- An appointment will be scheduled with an intake specialist to answer questions, address concerns, and obtain consent;
- A care manager will be assigned to discuss the family’s needs and concerns;
- The care manager will collaborate with the family to develop a plan of care to promote and enhance the child’s health and well-being.
- Monitor and assist with medical services and needs;
- Locate community resources and inform families about community-sponsored events;
- Coordinate educational needs and resources;
- Locate support groups for individuals and families;
- Assist with rehab and transitional services;
- Monitor Home and Community Based Services (HCBS), such as respite services, prevocational training, and ComHab services;
- Provide referrals for clinical therapeutic services;
- Assist with social services such as food benefits, home and health benefits, transportation, and community-based programs.