Our team will work with you and your existing supports to identify your needs, make a plan, and coordinate your care in various areas including: physical health, mental health, specialty care, benefits, housing, and other community resources.
Here are some examples of services our team can provide:
HEALTHCARE NAVIGATION
- Advocating for the highest quality care
- Arranging appointments and transportation to new or pre-existing providers
- Participating in hospital discharge planning
- Connecting participants to Home Health Attendant (HHA) services
APPLYING FOR & MAINTAINING BENEFITS
- Social Security
- Cash Assistance
- Food Stamps
- Medicaid & Medicare
- Housing & Transportation
CONNECTING TO RESOURCES
- Legal support
- Employment and educational support
- Specialty healthcare plans and services
Eligibility Requirements
To qualify for Care Coordination, you must:
- Be a resident of New York City
- Have active Medicaid
- Have been diagnosed with a mental illness
If you’ve experienced one or more of the following within the last 12 months, you may be eligible for more intensive services known as Health Home Plus:
- Lived in a shelter or slept on the street, motor vehicle, or other public place
- Visited the psychiatric emergency room 4 or more times
- Had 3 or more psychiatric inpatient hospital stays
- Had 3 or more medical inpatient hospital stays + carry a diagnosis of schizophrenia or bipolar disorder
- Discharged from a state psychiatric hospital
- Stepped down from ACT or AOT services OR currently on the ACT waiting list
- Released from jail or prison
We unfortunately cannot enroll anyone receiving the following services:
- ACT (Assertive Community Treatment)
- AOT (Assisted Outpatient Treatment)
- AOT-linked Care Coordination
- OPWDD (Office for People with Developmental Disabilities)
Get Connected
Referral Form
We accept self-referrals as well as referrals from professionals, friends, family members, etc.
Send completed forms to
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Questions / More Info
Leah Pressman
Director, Care Coordination
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212-780-1400, ext. 7791