Our Care Coordinators work closely with Medicaid Health Home enrollees to develop and implement person-centered plans of care designed to address their health issues – including physical health, behavioral health, and/or substance use – and the socio-economic challenges or unaddressed trauma that can create them.
We then help people to coordinate all their chosen services, supports, and resources into an overall “Wellness Team” – promoting and facilitating open, transparent, inter-agency communication to improve the quality, efficiency, and effectiveness of their ongoing care.
“We started in the late ‘90s, early 2000s and started embedding peers in the hospital in Kingston NY. The idea was to try to make the emergency department experience more engaging. We did not know what the term was back then then, but I guess we were using trauma-informed care. Over the years, as we worked there, we began to notice there were better alternatives to hospitalization. People were leaving the hospital then coming back very quickly. We saw an opportunity. We needed transitional care as a unique service. In the very most basic sense, we wanted to create something that would bridge people back to their homes in a way that would make the transition as smooth as possible.”—Joshua Gran, Chief Strategy and Development Officer