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Coordinated Care for People of All Ages

Coordinated care for complex challenges

Supporting individuals living with chronic illness(es), including, but not limited to: mental illness, substance use, asthma, COPD, diabetes, diseases of the heart, high blood pressure, obesity, ADHD, etc...

Our Care Managers help people achieve their desired optimal health using a collaborative team approach and effective coordination of services.

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Our Coordinated Care Services Include:

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Care Management for Seniors (NHTD)

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Care Management for Seniors (NHTD)

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The Nursing Home Transition and Diversion (NHTD) Waiver is one of the options available to New Yorkers with disabilities and seniors so they may receive services in the most appropriate, least restrictive setting.

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Childen's Health Homes (Care Management for Children)

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Care Management for Children (Health Homes)

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Coordination and care management for children with chronic illnesses including mental illness, substance abuse, asthma, COPD, diabetes, heart disease, high blood pressure and obesity, etc...

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Chronic Illness Case Management (HIV/AIDS)

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Case Management for Chronic Illnesses

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Getting the right care, treatment and support for individuals living with HIV/AIDS

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Employment Services for People with HIV/AIDS

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Employment Services for People with HIV/AIDS

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Helping folks with HIV/AIDS find gainful and sustainable employment in the community. Also referred to as Step Up To Employment.

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Expanded In-home Services for the Elderly Program - EISEP

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Expanded In-home Services for the Elderly Program - EISEP

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Helping seniors maintain independence

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HCBS and CORE (recovery services in the home or community)

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Mental Health and Recovery Services for the Home & Community

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Providing community recovery resources, employment support, and education for individuals recovering from serious mental illness or addictions.

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Health Homes (Care Management for Adults)

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Care Management for Adults (Health Homes)

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Adult Health Homes services offer linkage to many important resources for individuals and families such as access to food, cleaning supplies, assistance in application for benefits and entitlements, etc… Our care managers provide coordination and management services for individuals who are struggling with medical, mental, behavioral, and social needs. We support members to maintain connection with providers and receive the help they need.

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Housing Services for People with HIV/AIDS

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Housing & Stabilization Services for People with HIV/AIDS

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Helping persons living with HIV/AIDS find a safe, secure place to live.

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Support Services for People with HIV/AIDS

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Support Services for People with HIV-AIDS

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Services for people who are living with specific chronic illnesses to support their health and quality of life.

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Support to Aging Residents - STAR

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Support to Aging Residents - STAR

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Providing transportation and other supports to older adults to help people to remain independent in their homes.

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Transportation Services for People with HIV/AIDS

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Transportation Services for People with HIV/AIDS

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Medical Transportation services for individuals with HIV/AIDS for travel to medical appointments, support groups, pharmacy visits, Department of Health and Human Services and other related medical care.

available to individuals living with HIV/AIDS in Monroe, Chemung, Livingston, Ontario, Schuyler, Seneca, Steuben, Wayne and Yates counties.

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Traumatic Brain Injury

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Traumatic Brain Injuries

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Supporting individuals living with a Traumatic Brain Injury to achieve meaningful, self- identified goals, using both a collaborative team approach and effective coordination of services.

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Trustee Services

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Trustee Services

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Serving as the trustee for people who do not have the natural support or family to serve in that capacity. We provide our clients with the support they need for managing their supplemental needs and basic irrevocable trusts.

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