The Care Coordination Program serves the needs of individuals with who have chronic conditions. This special service emphasizes the treatment of the whole person and helps program participants manage and understand their conditions. To this end, Care Coordination integrates and coordinates all primary, acute, and long-term services and supports. The program also addresses social determinants of health, such as housing instability, food insecurity and social support, which often complicates health issues.
Who Are We?
We assist patients with serious & chronic health issues obtain the healthcare they need to stay healthy! Services are offered throughout all of Orange County.
What we do.
- Our Care Managers can assist you with accessing medical and mental health services to improve your health and wellness as well as advocacy.
- Advocacy for those with Mental Health Disorders, Substance Abuse, Alcoholism, Developmental Disabilities or Homelessness which includes:
- Assistance with scheduling appointments and medical transportation.
- Assistance with referral to medical, mental health or substance abuse services.
- Assistance in applying for and recertifying benefits. (such as Social Security, Public Assistance, HEAP, Supplemental Nutrition Assistance Program (SNAP) and more.
- Assistance accessing community resources.
- Monitoring support and crisis intervention as needed.
- Facilitation of discharge planning from an Emergency Room, hospital or residential/ rehabilitative setting to ensure a safe transition/discharge that ensures care needs are in place.
- Referral to peer services, supports groups, and other support services
- Coordination with treating clinicians to assure that services are provided and changes in treatment or medical conditions are addressed.
- Adherence to standard HIPAA laws by protecting your private information adequately.
You are eligible if…
- You have active Medicaid AND You have a need for service AND You have at least one of the following qualifying conditions:
- Two or more chronic medical conditions; that can be any combination of developmental disabilities, mental health, medical, and/or substance abuse diagnosis.
- A serious mental ill diagnosis
- You are HIV Positive
Specialized Case and Care Management (SCCM)
SCCM program provides intensive case and care management services to chronically homeless individuals.
Case managers work with people and families experiencing homelessness and those who are at risk of homelessness. Case managers identify households of greatest risk and determine the type of support needed to prevent homelessness. They also help clients develop independent living skills, provide support with treatment, and serve as the point of contact between clients and people in their social and professional support systems.
The goal is to find housing for the individuals involved in the program, as well as connecting with outside providers and resources.
Assisted Outpatient Treatment (AOT)
The Assisted Outpatient Treatment (AOT) program is a court-mandated initiative that provides intensive, coordinated support to individuals with serious mental illness who have experienced repeated hospitalizations or difficulties engaging in treatment. AOT ensures that individuals receive structured outpatient care while living in the community, reducing the risk of psychiatric crises, homelessness, or justice system involvement.
AOT Services Include:
- Case management and coordination of outpatient mental health treatment
- Assistance with medication management and adherence
- Support in securing stable housing and essential community resources
- Regular check-ins to monitor well-being and compliance with the treatment plan
- Collaboration with courts, medical providers, and community partners to ensure continuity of care
AOT is designed to enhance an individual’s ability to function independently while ensuring they receive the necessary mental health care to remain stable and safe in their community.
Social Care Network (SCN)
The Social Care Network (SCN) is a care coordination initiative established under the New York Health Equity Reform (NYHER) 1115 Waiver Demonstration. SCN aims to address health-related social needs (HRSNs) by connecting Medicaid recipients with essential services such as housing support, food security, transportation, and other community-based resources.
SCN Services Include:
- Comprehensive Care Coordination – Linking individuals with social services to address unmet needs
- Housing and Food Security Assistance – Connecting individuals with programs that provide stable housing, groceries, and nutritional counseling
- Transportation Services – Helping individuals access essential services such as mental health care, social services, and employment resources
- Employment and Education Support – Facilitating access to job training, educational programs, and financial assistance services
- Crisis Prevention and Stabilization – Reducing the risk of hospitalization, incarceration, or homelessness through early intervention and case management
SCN is designed to integrate health care providers, social service agencies, and community-based organizations to improve overall well-being and long-term stability for individuals facing complex challenges.
SERVICES ARE FREE AND PERSON-CENTERED
Please contact us to schedule a day and time when you can meet with our Outreach Care Manager to learn more about how we may be able to assist you or make a referral via our online platform or Email us at: adavenport@mhaorangeny.com
CONTACT US: Care Coordination (845) 342-2400 ext. 1225 Care Coordination Supervisor (845) 342-2400 ext. 1244 of submit a referral via the Care Management Programs Referral Form
Online Forms and Additional Resources: Care Coordination Brochure in English Folleto de Coordinación de Cuidados en Español
