Westchester County’s Care Coordination Program is for adults with serious mental illness who have had limited participation in community services. Limited participation plus inadequate support networks often result in repeated hospitalizations or incarcerations, homelessness, frequent crises, and injury to self or others. Evidence shows that care coordination improves outcomes for individuals and benefits communities.

Eligible participants will be 18 years of age or older, have a serious mental illness (primary DSM-IV diagnosis) and will have experienced one or more of the following:

  • Frequent use of emergency rooms, acute psychiatric inpatient units, psychiatric centers and other acute or crisis services with no link to community-based services
  • Discharges from jail or prison with no active link to services
  • Frequent arrests and incarcerations
  • Homelessness
  • Enrollment is voluntary

Program Details
Each enrollee will work with a Care Coordinator. Care Coordinators will:

  • Assist the enrollee with the development of an Individualized Services Plan (ISP) to identify services, supports and providers that will help in recovery, wellness and satisfaction
  • Use best efforts to provide or arrange for desired services and supports
  • Ensure that services are being provided as identified by the ISP
  • Support the ISP as the single plan for service delivery
  • Play a formal or informal role relative to the utilization of inpatient services
  • Help enrollees establish and maintain Medicaid, housing and other public assistance benefits
  • Promote rehabilitation, recovery and wellness into all program activities

Values and Principles
Person-Centered planning and service delivery are at the center of the Care Coordination Program. The ISP is developed based upon the values and principles listed below. Person-Centered planning and service delivery are successful when:

  • Activities, services, and supports are based upon the individual’s interests, preferences, and strengths
  • Those who are important to the individual are included in lifestyle planning
  • Opportunities to exercise control and make informed decisions from meaningful choices
  • Participation fosters skills needed to achieve personal relationships, community inclusion, dignity, and respect
  • Planning is collaborative and recurring
  • The person is satisfied with their choices

Recovery Mentors
If given the opportunity, some with serious mental illness prefer to work in partnership with those who have similar histories and who have achieved independence and satisfaction with their quality of life. Westchester County supports this approach and provides access to recovery mentors through program enrollment.

Self-Determination Funds
The majority of mental health services are paid for by Medicaid.  Medicaid requires that services be "medically necessary." Individuals with serious mental illness often need other services — like housing and job-training. Medicaid does not cover the costs of these services. But, the self-determination funds can be used to assist with access to these other and important services.

There is no cost to the individual or family for these services. The program is funded through the New York State Office of Mental Heath and is operated by the Westchester County Department of Community Mental Health and the Mental Health Association of Westchester.

For further information or to make a referral, contact us by phone at (914) 995-5245, by fax at (914) 995-5172 or by e-mail at .