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Health Home Care Management
Our newest initiative in the comprehensive care of medically complex children brings our knowledge of community resources and services to your home.
What is a Children’s Health Home?
A Children’s Health Home isn’t a place! It’s a type of care that allows for health care and service providers in the community to work together to make sure that your child receives the care and support services to stay healthy.
What is a Care Manager?
Once your child is enrolled in a Children’s Health Home, a care manager will work with you to develop a care plan to address your child’s specific needs. In addition to helping you to connect with the right providers and make appointments, your care manager can assist you with housing or transportation issues, social service needs (such as SSI, food stamps, WIC), school placement and supports, medications or equipment, or other community supports.
How do I know if my child qualifies for Children’s Health Home Services?
If your child receives Medicaid and has two or more chronic conditions, he or she may be eligible for the program. There is no cost to enroll in the program and you can choose to disenroll at any time. Your Medicaid and social service benefits will not change.
Is Blythedale a Children’s Health Home?
Blythedale provides care management services to members enrolled in our partner Health Homes. Given our many years of experience working with medically complex children, we are proud to offer our expertise to this exciting New York State initiative.
Our Partner Health Homes:
Bronx Accountable Healthcare Network (BAHN)
(855) 680-2273
Skyward Health
(888) 980-8410
How Do I Find Out More?
You can call Medicaid at (800) 541-2831 or click here.
For more information about services in Westchester, please contact Jessica Hurtado, L.M.S.W.
For more information about services in the Bronx, please contact Decsiree Gonzalez, L.M.S.W. or Crystal Jones, L.M.S.W.
24/7 emergency line for members and families - (914) 610-6034
Contact Information:
- Susan Murray, L.C.S.W., Vice President, Patient/Family Experience, Clinical Outreach, and Care Coordination
- smurray@blythedale.org
- 914-831-2443
Health Home Care Management Staff

Our social work care managers have masters degrees in Social Work and New York State licensure. They have a vast knowledge of the resources available to medically complex children in local communities and help parents tie all the pieces of a complex care plan together to help each child reach his or her potential. Your care manager is able to make home visits, attend medical appointments or school meetings with you, and link you to social service agencies to provide support. She is your partner in the care of your child.
Treatments We Support
Pulmonary Rehabilitation
The goal of the Pulmonary Rehabilitation program is weaning from technology completely or to the least invasive support to facilitate the family's transition to home. Parents are involved in the care of their child every step of the way, and learn proper use of equipment, care of tracheostomy,...
Learn morePulmonary Hypertension
Blythedale’s expertise in caring for the most medically fragile of children is evident in our Pulmonary Hypertension rehabilitation program. Children come to Blythedale directly from the Intensive Care Unit while receiving intravenous, inhaled, subcutaneous or oral medications for pulmonary...
Learn moreAcquired Brain Injury
Blythedale Children’s Hospital is a longtime leader in the treatment of children recovering from brain injury including Traumatic Brain Injury (TBI), post-infectious diseases such as meningitis or Anti-NMDA receptor encephalitis (ANMDAR), brain tumors and stroke. The extraordinary...
Learn moreAssistive Technology
Assistive Technology expands opportunities for children with special needs to increase participation in school settings, build social interactions, and access their environments in a variety of specialized ways. Blythedale’s dedicated team includes Assistive Technology experts from speech...
Learn moreCancer Rehabilitation
A customized therapeutic regimen enables patients to regain their strength and function while undergoing or recovering from surgery, chemotherapy and/or radiation therapy. We recognize the vital importance of an ongoing relationship with the child’s referring oncology team, and we participate...
Learn moreCardiac Rehabilitation
As more infants and children are undergoing complex cardiac surgical procedures to repair congenital conditions such as hypoplastic left heart syndrome, tetralogy of fallot, transposition of the great vessels, coarctation of the aorta, or cardiac injury due to myocarditis or traumatic injury,...
Learn moreComplex Chronic Conditions
Many children come to Blythedale with multiple, complex chronic conditions that impact their function. These chronic conditions - including cerebral palsy, CHARGE syndrome, congenital and chromosomal abnormalities, severe epilipsy - can complicate recovery after surgeries, acute illnesses or...
Learn moreComplex Post-Surgical Rehabilitation
Patients are admitted for acute medical and rehabilitative inpatient care following major trauma (such as head and spinal injuries, extensive soft tissue trauma/burns, vascular injuries, major muscle/ligament injuries, amputations or fractures), extensive scoliosis surgery, selective dorsal...
Learn moreComplex Wound and Burn Management
The child’s clinical team works collaboratively with parents and other caregivers to identify developmentally appropriate medical and therapeutic goals. This team is also committed to meeting the psychological and social challenges that accompany burn and wound treatment and recovery,...
Learn moreNeuromuscular Disorders
The goal of our Neuromuscular Disorders program is to help children maximize their functional abilities through comprehensive medical care and rehabilitation, utilizing state-of-the-art technology, environmental modifications and adaptive equipment. Following an intake evaluation, the child’s...
Learn morePost Acute Neonatal Care
Whether requiring ongoing medical management and rehabilitation due to extreme prematurity, bronchopulmonary dysplasia, congenital cardiac disease, pulmonary hypertension , hypoxic-ischemic encephalopathy, short gut syndrome, feeding disorders or other complications occurring in the neonatal period...
Learn morePre/Post Organ & Stem Cell Transplant
These children require the highest level attention of a multidisciplinary team of pediatricians, pediatric physiatrists, nurses, nutritionists, pharmacists and physical, occupational, speech and feeding therapists familiar with the problems inherent in recovery from and living with a transplant. We...
Learn moreSpecialized Feeding
Children referred to Blythedale for Therapeutic Feeding have wide-ranging conditions including prematurity, short-gut syndrome, brain injury, oral-motor dysfunction, aversion behaviors, cognitive deficits or post-surgical complications. Services for these children include evaluations for both...
Learn moreThe Magic of Health Home
When asked about who Noah is, his mom, Katy, replied, “Noah is an amazing little boy. Well, I shouldn’t say little boy anymore because he’s 15, but to me he’s always going to be my little boy.”
Learn more about how Noah and Katy were part of the magic of Health Home with the assistance of their Health Home Care Manager, Crystal Jones, L.M.S.W.
Brave Bentley: Health Home Helps Medically Complex Boy & Family Thrive in Community
"He's the bravest kid in the world and an inspiration for anybody."
Bentley is more than his power wheelchair, life-sustaining ventilator and assistive technology devices. Lovingly referred to as the "Mayor of Blythedale", Bentley is a trailblazing patient and one of our first Health Home Care Management members. Learn how Bentley and his mom overcame his progressive neuromuscular disorder and thrived, both during his treatment at Blythedale Children's Hospital and beyond.

Knowledgeable Naphtaly
Naphtaly knows Blythedale.
His lengthy and complex medical journey led him to Blythedale over the course of 12 years as an inpatient, a Day Hospital patient, an outpatient, and most recently, an enrollee in the Hospital’s Health Home Care Management Program.
Nineteen-year-old Naphtaly, with the support of Health Home Care Manager Elizabeth Grossfeld, LCSW, is learning to take an active role in his health care.