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Care Coordination

The heart of this program is client centered individualized service planning and assistance in securing access to services to help individuals in their recovery. Each participating county designates "Care Coordination Organizations" that:

  • Collaborate with county sponsored Single Point of Access (SPOA) to identify individuals who might benefit from the care coordination program and offer them the opportunity to enroll in the program
  • Work with enrollees to develop individualized service plans
  • Work with providers to arrange admission into desired or needed services
  • Coordinate mental health, chemical dependence, medical, legal, housing and needed support services
  • Provide ongoing case management services
  • Participate in systematic efforts to monitor the appropriateness of treatment
  • Work with county governments to coordinate access to supportive housing

Eligible Persons

The Care Coordination program provides support to adults diagnosed with serious mental illness with a high need for clinical and support services. Individuals may have histories of repeated hospitalization or incarceration, experience frequent crises, experience an absence of a constructive social or family network, lack meaningful activity, and experience difficulties engaging in treatment, taking prescribed medications and/or managing their symptoms of illness.

Values and Principles

The following "values and principles" underlie this program:

  • Development of an Individualized Service Plan (ISP) that is unique to the needs and desires of the individual.
  • Individuals are full participants in all aspects of the development of the ISP and in the selection of services and providers. Family members, peers, or others may participate in this process with agreement of the individual.
  • Services should be delivered in the least restrictive, most normative environment that is appropriate to the individual.
  • Best efforts are made to ensure that individuals have access to services within the first 24-hours following referral from the Single Point of Access (SPOA) and as needed on an ongoing basis.
  • Participating providers agree to give individuals priority access to services.
  • Participating providers agree to cooperate and collaborate with the Care Coordinator to implement the Individual Service Plan.
  • Coordinated, flexible use of available financial resources empowers Care Coordinators to purchase services and make effective linkages to providers to meet the needs of individuals.
  • Progress towards a rehabilitation and recovery model by ensuring access to a comprehensive array of all human services that addresses the individual's specific needs.
  • Coordination of mental health, medical, substance abuse and all other human services.
  • Linkages with all health and other human support services.
  • Cultural competency in service delivery.
  • Continuous improvement of the Care Coordination Program by monitoring utilization and outcomes on an individual basis.
  • Promotion of implementation of evidence based best practices.
  • Respect for the privacy of individuals.

Care Coordinators

Each person who enrolls in the program will work with a Care Coordinator. Care Coordinators will provide the following services:

  • Work with individuals to develop an ISP, identify services needed to support recovery, and select providers who will partner with them in their recovery.
  • Use best efforts to provide or arrange for individuals to receive needed services.
  • Monitor implementation of the ISP and support the empowerment of individuals to ensure that the delivery of services are in accordance with the ISP.
  • Play a formal or informal role relative to the utilization of inpatient services.
  • Coordinate with organization(s) designated by the counties as Single Point of Access (SPOA) for Case Management and housing services as well as other critical services.
  • Assist individuals in establishing and maintaining eligibility for Medicaid and other public assistance benefits.
  • Work with counties to monitor access to services for individuals.
  • Complete outcome reports and provide information consistent with program requirements.

Care Coordination Forms

NYCCP Care Coordinators use the following forms: