Coordinated Care

Thoughtful coordination – which ensures that each person gets the services they need – has many components. Coordinators provide outreach, advocacy and referrals to help link the people they work with to the most appropriate services, whether related to health, housing or employment. Coordinators help make sure that offerings are integrated so that the person receiving the services gets the greatest possible benefit.

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Service Coordination for people with Intellectual and Developmental Disabilities

Medicaid Service Coordination (MSC)
People with complex needs can almost always use help finding and arranging for the services and supports that will best help them reach their potential. Medicaid Service Coordinators (MSCs) are familiar with the system of care and trained to guide and advocate for people with intellectual and developmental disabilities. Coordinators help to create an Individual Service Plan around each person’s goals, clarify eligibility for services and coordinate different providers and supports to meet individual needs.


Service Coordination for People Without Medicaid
Family Assistance providers help those people with developmental disabilities who live at home with their families and are not eligible for Medicaid or Medicaid Service Coordination. The coordinator advocates and provides information while linking individuals to the services they need. These may range from educational help, applying for benefits, providing information on social and recreational activities, referral to work supports and understanding and getting access to OPWDD services.

When Only Minimal Medicaid Service Coordination is Required

Some individuals enrolled in the NYS OPWDD Home and Community Based Developmental Disability Waiver may use a Plan of Care Service (PCSS). Their ISP only needs to be reviewed twice a year and there may be an occasional need for assistance, up to two more times a year.

Care at Home

Medically fragile children enrolled in the Care at Home waiver can be eligible for Medicaid based on the child’s income and assets with the parents’ income waived. This covers service coordination, environmental modifications and adaptive technology not usually paid for by Medicaid.


Care Coordination

Almost everyone with complex needs, whether they arise from serious mental illness, aging or physical issues, benefits when services are intelligently coordinated.
Our Case Managers help connect needed services in many ways, advocate for the people they work with and making referrals. These span services related to everything from housing to employment to health, and the goal is always to integrate various offerings in a single coordinated plan.



Specialty Case Management Services

People with complex needs, whatever the cause, share the need for a plan that connects and coordinates various therapies and services. Our Case Management Services are offered to a variety of people receiving multiple supports. These include young people with serious emotional and behavioral challenges; adults with mental illness transitioning from jail, prison or a psychiatric hospital; and those who are homeless and living with serious behavioral health needs.


People with Physical Disabilities and the Elderly

Supporting Independence: The Nursing Home Diversion and Transition Waiver

We assist individuals with disabilities and seniors in making the transition from a nursing facility…or avoiding placement in one. Our goal is to have the person receiving services play a central role in building a personalized plan around their distinct strengths, needs and goals. This process works for everyone, promoting independence while reducing the expense associated with longterm care facilities.

Help Selecting the Right home Care Assistant

The Consumer Directed Personal Assistant Program (CDPAP) is designed for individuals who get assistance in their home. The purpose is simple: to give the recipient a central role in selecting, hiring, training and supervising their aide. CDPAP serves as the fiscal intermediary (FI), facilitating payroll, benefits, billing and administration. Serving residents of Orange, Sullivan and Ulster Counties.


Services for People with Traumatic Brain Injury

Service Coordination

An individualized plan is the centerpiece of the offering and each plan is based on a careful assessment of needs and developed by the coordinator with the individual involved. Individual Living Skills Training, when there is a need, may be included as part of the plan.

Independent Living Skills Training

Re-gaining independence after a traumatic brain injury can be difficult. This service provides expert help to re-train effected individuals in everything from self-care to socialization, sensory skills to task completion. Participants in the program can also get help with managing the effects of the injury in their daily lives.

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