Health Home Services
Health Home Services provides coordinated and comprehensive medical and behavioral health care to patients with chronic conditions. By integrating important key aspects of care, we assure access to appropriate services which improve health outcomes, reduce hospitalizations and emergency room visits, and promote use of health information technology (HIT). This symphony of services provides a holistic approach to comprehensive care.
- Comprehensive care management
- Health promotion
- Transitional care including appropriate follow-up from inpatient to other settings
- Patient and family support
- Referral to community and social support services
- Use of health information technology to link services
For additional information or to speak with someone to see if you qualify for Health Home Care Management please contact Central Intake at 716-701-1135.
Medicaid Service Coordination
A Medicaid Service Coordinator, MSC, provides information and options to individuals and their families to help them make informed choices. The MSC assures the person has a good understanding of their situation and has their questions answers.
The goal of service coordination is to assist individuals with developmental disabilities and behavioral health issues identify their needs and obtain the supports and services to meet those needs. The ReHabilitation Center’s service coordinators help individuals with Medicaid enrollment and the eligibility review process with the Office of People with Developmental Disabilities’ (OPWDD).
When an individual is interested in an OPWDD Home and Community-based Waiver service, a service coordinator is required. The individual will also require Medicaid enrollment and an OPWDD eligibility determination.
Comprehensive Assessment /development of specific care plan and periodic review
Together, the individual and MSC identify valued outcomes and necessary supports and services. They will also develop an individualized service plan which is reviewed at least twice a year.
Advocacy, linkage, referral, and related activities
The MSC can assist an individual in advocating for themselves with family, programs, and service providers. MSCs will link and refer individuals to OPWDD and community services best suited to addressing the individuals valued outcomes.
Monitoring and follow-up
The MSC will meet with the individual and/or their family several times per year. During these meetings, the MSC will discuss current services, health/safety concerns, satisfaction with current services, and the individual’s desire/need for additional services.
- Medicaid Eligibility
- Community Habilitation
- Day Habilitation/Day Treatment
- Residential Habilitation
- Family Education and Training
- Self-Directed Services
- Environmental. Modifications
- Adaptive Technology Funding
- Family Reimbursement Funding
- Vocational Services
For additional information or to speak with someone to see if you qualify for Medicaid Service Coordination, please contact Central Intake at 716-701-1135.
Traumatic Brain Injury (TBI) Service Coordination
A Service Coordinator assists the participants in the development, implementation, and monitoring of all services in the Service Plan. Additionally, the Service Coordinator initiates and oversees the assessment and reassessment of the participant’s level of care and on-going review of the Service Plan, assessments, new and ongoing services.