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Community Based Programs

Care Coordination Programs

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.


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: 

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: Brochure

Our Impact 2023

  • People Served


  • Meals Served/Delivered


  • Hours of Contact


  • Transportation to Services


© 2024 Mental Health Association in Orange County Inc.

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