Make a Referral Today

You know how important it is to treat the whole patient.

Every day you encounter patients who need help navigating the health care system, who may lack transportation, housing, or food, and/or whose environment makes it difficult for them to get and stay healthy. With a patient waiting in the next room and limited time and resources, how can you address the “whole patient”?

Monroe Plan’s Health Home Care Management Agency offers a solution. Patients enrolled in Medicaid or dually enrolled in Medicaid and Medicare may be eligible for care management services that help address their health care holistically.

To learn more, make a referral, or if you have questions, contact us:

Or complete the form below and email it to us at

Who is Eligible?

Adult and Children who qualify for Medicaid and individuals who have both Medicaid and Medicare, including those who are already members of a managed care organization, who meet one of the following conditions:


  • With two or more chronic health conditions, such as asthma, diabetes, heart disease, mental health condition or substance use disorder or
  • With a significant mental illness or
  • Who are living with HIV/AIDS and
  • Have one or more significant risk factors such as:
        • Homelessness or risk of homelessness
        • Lack of social/family suppoort
        • Non-adherence to treatments
        • Learning or cognitive issues
        • Deficits in activities of daily living


  • With two or more chronic health conditions or
  • Who are living with HIV/AIDS or
  • Who are living with complex trauma
  • With a serious emotional disturbance and
  • Have a significant risk factor(s) which can be address through care management such as:
        • Behavioral
        • Medical
        • Social