Care Coordination
Care Coordination supports individuals living with chronic health conditions by addressing the needs of the whole person. Care managers help participants understand and manage their health while coordinating primary care, behavioral health, acute care, and long-term services and supports.
The program also helps address nonmedical needs that can affect a person’s health, including housing instability, food insecurity, transportation, and limited social support.
Who We Serve
Care Coordination serves individuals throughout Orange County who have chronic medical, behavioral health, developmental disability, or substance use needs.
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: ccoordination@mhaorangeny.com
CONTACT US: Care Coordination (845) 342-2400 ext. 1225 - Care Coordination Supervisor (845) 342-2400 ext. 1244 or 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
What We Do
Care managers work with participants, healthcare providers, and community organizations to coordinate services and help participants achieve their health and wellness goals. Services may include:
- Connecting participants with medical, mental health, and substance use treatment
- Advocating for participants across healthcare and community service systems
- Assisting with scheduling appointments and arranging medical transportation
- Helping participants apply for or recertify benefits, including Social Security, Public Assistance, HEAP, and the Supplemental Nutrition Assistance Program (SNAP)
- Connecting participants with housing, food, financial, and other community resources
- Monitoring participants’ needs and providing crisis support when necessary
- Coordinating discharge planning from an emergency department, hospital, residential program, or rehabilitation setting
- Connecting participants with peer services, support groups, and other supportive resources
- Coordinating with treating providers to ensure services are delivered and changes in medical or behavioral health needs are addressed
- Protecting participants’ health information in accordance with HIPAA and other applicable privacy requirements
Eligibility
Individuals may be eligible for Care Coordination if they:
- Have active Medicaid
- Have an identified need for care coordination
- Have at least one of the following:
- Two or more chronic health conditions, including medical, mental health, developmental disability, or substance use conditions
- A serious mental illness
- HIV/AIDS
Specialized Case and Care Management
Specialized Case and Care Management (SCCM) provides intensive case and care management services to individuals and families experiencing homelessness or at risk of becoming homeless.
Case managers assess each household’s needs and identify the services and supports that may help prevent or end homelessness. They also help participants develop independent living skills, engage in treatment, access community resources, and communicate with members of their personal and professional support networks.
The goal of SCCM is to help participants obtain and maintain stable housing while connecting them with the services and resources needed to support long-term stability.
Assisted Outpatient Treatment
Assisted Outpatient Treatment (AOT) is a court-mandated program that provides intensive, coordinated support to individuals with serious mental illness who have experienced repeated hospitalizations or difficulty remaining engaged in treatment.
AOT helps participants receive structured outpatient care while living in the community. The program is intended to reduce psychiatric crises, homelessness, hospitalization, and involvement with the justice system.
AOT Services
Services may include:
- Case management and coordination of outpatient mental health treatment
- Support with medication management
- Assistance obtaining stable housing and essential community resources
- Regular check-ins to monitor participants’ well-being and progress with their treatment plans
- Coordination with courts, healthcare providers, and community partners to support continuity of care
AOT is designed to help participants remain safe and stable in their communities while strengthening their ability to live as independently as possible.
