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Medical Care Coordination

Dedicated coordinators to help address your individual medical needs

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Assisting people with serious physical and mental health conditions

Our team supports people receiving Medicaid who live with chronic health conditions, and/or mental health and substance use challenges. We help you get the resources you need to remain healthy and safe in your community.

We can help with

- Finding a doctor or specialist and coordinating your medical care
- Help after discharge from the hospital
- Transportation to medical appointments
- Understanding confusing medical information
- Appointment scheduling and reminders
- Connecting you to financial assistance for food, housing, and other basic needs
- Helping you access and navigate social services and community programs like DSS, SSA, HEAP, and more
- Access to HIV medication

Apply for Care Coordination Services

How does it work?

Step 1: Meet

In the first meeting with your Care Coordinator, you'll discuss your challenges and goals.

Step 2: Create a plan

Your Care Coordinator will work with you to create a plan to address your immediate needs including housing, food, transportation, and medication access.

Step 3: Follow the plan

Review your goals on a timely basis to make sure you are on track with a focus on prevention methods to help avoid emergency rooms or hospital visits.

Who is eligible?

To qualify, you must have

HIV/AIDS* and be Medicaid eligible OR
Two or more chronic conditions like Substance Use Disorder*, Asthma, Diabetes, Heart Disease, High Blood Pressure, and Morbid Obesity OR
One single qualifying chronic condition
- Serious Mental Illness* (Adults) OR
- Sickle Cell Disease (Adults and Children) OR
- Serious Emotional Disturbance or Complex Trauma (Children)

*If an individual has HIV or Serious Mental Illness, they do not have to be at risk for another condition to be eligible for Medical Care Coordination services. Substance Use Disorders are considered chronic conditions and do not, by themselves, qualify an individual. Individuals with Substance Use Disorders must have another chronic condition to qualify.

Apply Today

What Clients Say

Changing lives by meeting people where they are.

Tell us your experience

I went here for the first time to get free testing and got a test that was administered by Brooks. This place not only has the most calmest ambiance, but the nicest staff ever, especially Brooks. I couldn't have had a more comfortable, validating, non-judge-mental, and overall positive experience.

Anonymous

Frequently asked questions about medical care coordination

Where can I access Medical Care Coordination?

In each of our five locations throughout Northeastern New York.

How will this affect my current health services?

Your current health services should not be interrupted. You will not have to change medical providers or managed care programs. Your connection with Medicaid will NOT change.

How do I qualify?

To qualify, individuals must

Medicaid eligible and have HIV/AIDS or,
Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes, Heart Disease, High Blood Pressure, morbid obesity) or,
One single qualifying chronic condition:
- Serious Mental Illness* (Adults) or,
- Sickle Cell Disease (both Adults and Children) or,
- Serious Emotional Disturbance or Complex Trauma (Children)

*If an individual has HIV or SMI, they do not have to be determined to be at risk of another condition to be eligible for Health Home services. Substance use disorders (SUDS) are considered chronic conditions and do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition to qualify.