Primary Care and Prevention Focused Care Model (PCPFCM)

NH Healthy Families understands you may need assistance navigating the healthcare system. We offer care management services to assist with scheduling appointments, arranging for transportation, housing, and connecting you with community resources such as food stamps, utilities, and support groups. 

Care Management is available for all participants. You or your doctor can refer for care management services. You will be assigned a primary care manager who will contact you through the method of communication you prefer, at a time you choose as well. Your care manager will work with you, your PCP, all of your other providers, your family and caregivers, and other health insurance you have to make sure that you get all of the series that you need. We will develop a plan of care and share this plan with your PCP or provider(s). The plan of care has  goals for you to work towards. There is no fee or charge to your participation, and you can choose to dis-enroll at any time. 

Our Care Managers are registered nurses, behavioral health clinicians or social workers. They help our members understand major health problems and assist in arranging members’ health care needs. Care Managers work with members and their providers or doctors to help identify barriers and support the provider’s plan of care. We also will provide support to your caregivers and family members taking care of you if needed. 

Members enrolled in care management often see several doctors. They may need medical supplies or help at home. NH Healthy Families’ Care Managers can assist members in coordinating aspects of their care. Members enrolled in Care Management often have conditions such as, Organ Transplants, Cancer, Hemophilia, Depression, Bipolar Disorder, Autism, and/or Breathing Problems. 

Your care manager will also help you when you are leaving the hospital or other short-term medical setting to make sure you get the services you need when you get home. These services may include home care visits or therapies. If you need help with any part of your health care services or with connecting with another state or local program, please call your care manager or Case Management Department at 1-866-769-3085. 

In addition to Care Managers, NH Healthy Families has Coordinators who specialize and work with Care Managers in coordinating care. These coordinators are dedicated to the following issues: Developmental Disabilities, Special Care Needs,  and Housing Needs. Through our Transition Services program, Coordinators also contact members who have admitted or readmitted to acute care hospitals to make sure you have a successful transition back into the community.

New Members: Your chosen PCP, or the PCP that has been assigned to you is indicated in your member packet. If that PCP differs from who you are currently seeing, or would like to see, we can help!

Existing Members: If you can’t find your PCP,  or if you want to change your current PCP for any reason, we can help!

• Contact the PCP you want to see to find out if they are accepting new patients
• Phone: Call Member Services to make the change in our files 1-866-769-3085 OR
• Online: Log into your secure portal to update your PCP OR
• By Mail: Complete and mail the PCP Change Form (PDF) to us

For a list of PCPs in network, view our Provider Directory.

• Welcome Kit Primary Care and Prevention Focused Care Model (PCPFCM) (PDF)
• Primary Care and Prevention Focused Care Model (PCPFCM) FAQ (PDF)
• Welcome Kit Forms Booklet (PDF)
• Health Risk Assessment (HRA) (PDF)
• Health Risk Assessment (HRA) - Spanish (PDF)
• PCP Change Form (PDF)
• Member Handbook Effective September 1, 2024
• Provider Directory