Health Homes provide comprehensive care coordination and support for individuals with complex behavioral health, medical, and social needs enrolled in a Psychiatric Rehabilitation Program (PRP). Our team works closely with participants, families, healthcare providers, and community partners to ensure every person receives the care and
resources needed to improve their health and quality of life.
Home Health Services
Currently serving eight (8) counties in the Eastern Shore region(Dorchester, Talbot, Queen Annes, Caroline, Kent, Wicomico, Worcester and Somerset).
Locations:
We use secure health information technology to continuously monitor outcomes and improve service delivery. By tracking quality metrics and participant satisfaction, we ensure our care evolves as you do.
Why Choose Home Health
Achieve long-term stability and wellness
Improve overall physical and mental health
Reduce hospitalizations and emergency room visits
Strengthen independence and self-management skills
Connect to vital community resources
Our Goal for Every Participant:
Core Services
- Individualized care plans with measurable goals
- Collaboration with primary care providers and specialists
- Ongoing monitoring and population-level trend tracking to improve outcomes
Comprehensive Care Management
We start with a deep dive into your physical and behavioral health, substance use history, and social needs.
Care Coordination
We ensure you receive the right care at the right time by breaking down barriers between providers.
- Coordination following hospital or ER visits
- Medication reconciliation and home outreach post-discharge
- Support during transitions to adult services or community living
Health Promotion
We empower you with the knowledge to maintain long-term wellness.
Comprehensive Transitional Care
Moving between care settings can be stressful. We ensure you don't fall through the cracks.right time by breaking.
- Scheduling medical appointments and obtaining records
- Referrals to specialists and community agencies
- Tracking immunizations and preventive screenings
- Chronic condition management and medication education
- Healthy lifestyle counseling (nutrition, exercise, smoking cessation)
- Substance use prevention and recovery support
"Our goal is to help you build the confidence and knowledge needed to manage your health conditions effectively."
