ECMC Emergency Department team members.
By Courtney McDermott

On Aug. 1, the Erie County Medical Center (ECMC) Emergency Department (ED) began offering Health Home services to Medicaid clients who visit the ECMC ED.

This new Health Home access has been made possible thanks to the leadership of Lucia Rossi, MAOL. Director of Outpatient Operations Primary Care, ECMC; and the collaborative efforts of ECMC ED team members and three leading area Health Home organizations including Health Home Partners of WNY; Greater Buffalo United Accountable Healthcare Network (GBUAHN), and BestSelf Recovery Community.

“Staff and providers in both inpatient and outpatient settings, are working diligently and passionately every day inside the walls of their organizations to provide their patients with the highest level of care and compassion, only to be met with barriers that their patients are experiencing outside in their everyday lives,” explained Lucia Rossi. “Integrating Health Homes into our organization will create a bond with our patients out in the community that will undoubtedly enhance their healthcare and overall quality of life.”.

This new collaboration was facilitated by team members from Millennium Collaborative Care including Dr. Anthony J. Billittier IV, Chief Medical Officer and an emergency physician with UB|MD; Janet Stoeckl, Clinical Director; and LaTonya Diggs, Behavioral Health Manager.

“I’m very proud of the work both ECMC and our Health Home partners have put in to make this happen,” explained Janet Stoeckl. “Millennium’s role was as a facilitator. We brought knowledge and information on best practices, and our relationships with ECMC and the Health Home providers. They all did the heavy lifting to establish this new service.”


A “Health Home” is a free community care management service that focuses on eligible Medicaid beneficiaries with multiple chronic conditions.

Health Home enrollees receive a dedicated Care Manager who oversees and provides access to comprehensive services with the primary objectives of helping the client stay healthy and therefore not requiring emergency room services nor hospital admittance.

There are many benefits of Health Home enrollment including:

  • personalized comprehensive care management
  • care coordination and health promotion
  • comprehensive transitional care
  • patient and family support
  • referral to social and community social support services.


As of Aug. 1, ECMC Emergency Department patients now have access to three Health Home providers on a rotating monthly basis including:

During a patient’s visit to the ECMC Emergency Department, ECMC staff meet with the patient to connect her/him with the Health Home of their choice; or to check if they already have an existing Health Home.

Once the Health Home is determined, ECMC staff will contact the respective Health Home to inform them that the Medicaid patient was in the Emergency Department. The Health Home that the patient belongs to (or would like to belong to) will in turn follow up with the patient and document the appropriate information needed in the Health Home database, and make plans – if necessary – for follow up care coordination.

“This project is a continued effort to strengthen the relationship and bi-directional communication with Health Home providers across the hospital system,” explained LaTonya Diggs, Behavioral Health Manager, Millennium Collaborative Care. “It will allow Health Homes more direct access to eligible patients as well as provide an increased level of communication back to the hospital about the Health Home status of patients visiting ECMC.

“They (ECMC) are starting their efforts in the Emergency Department with plans to expand into primary care next,” LaTonya added.


Thanks to ECMC staff’s willingness to share best practices with Kaleida Health, and continued facilitation support from Millennium, Health Home/Emergency Department integration is expanding to Buffalo General Medical Center with a fall target date for Buffalo General’s Emergency Department to offer its Medicaid patients Health Home services.


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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

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