Care Coordination Services

The Care Coordination Program assumes on-going primary responsibility for an assigned caseload of members in order to coordinate, implement and evaluate his/her plan of care in the members private residence, shelter or transitional housing setting. The Care Coordinators coordinates activities with other providers to ensure optimal care for the members. The focus includes a comprehensive assessment of a member who is in a transition of care situation including hospital discharge, an assessment of needs for the member who is at-risk for non-compliance to a treatment plan or for a member who is at high risk for a readmission to the hospital. For those who are in need for housing, the care coordinators collaborate with housing programs in an effort to find suitable and appropriate housing for the members and/ or their families.

To be eligible you must have one of the following:

•    Mental Health Condition
•    Substance Use Disorder
•    Asthma
•    Diabetes
•    Heart Disease
•    Overweight as evidenced by a body mass index (BMI) of >25
•    HIV/AIDS
•    Hypertension

Services provided:
•    Assessment & Evaluation
•    Individual Counseling
•    Preventive Educational
•    Case Management Services
•    Behavioral Health Services
•    Emergency Food Pantry
•    Referrals for Medical, Drug TX & Support
•    Psychiatric
•    Transportation Assistance

For more information on these programs, please contact Maryse DeZulmat at (646) 548-0100 x244 or [email protected]