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Adult Mental Health Care Coordination
Our programs provide community-based services to adults with a diagnosis of serious mental illness who are struggling to manage or make progress in their pursuit of the quality of life they desire, and are seeking greater levels of wellness, independence, and personal satisfaction and success in their lives.
Our philosophy is that the individual is the center of the recovery process with the rights and abilities to explore any avenue that will aid in this process. The intent of services provided is to support people in the selection, preparation, and obtainment of their recovery goals. The care coordinator’s role is to insure that the person’s recovery plan works well for them and to coordinate all steps involved in carrying out the plan.
Individuals define their own vocational, educational, housing, financial, and social life goals. Additional areas of focus often include community involvement, access to health care services for mental health, physical health, and chemical dependency issues, access to transportation, and reduction of use of crisis and inpatient services.
Individuals and their care coordinators partner together to determine what opportunities and supports are needed to progress with these goals. In the context of helping people to reach their goals, care coordinators engage in community outreach to help people connect to our services, make linkages to a wide variety of other services and supports, coach the person to resolve internal and external barriers to recovery, and coordinate connections between multiple services to insure that they uniquely meet the person’s needs and desires.
An emphasis is put on the inclusion of formal and natural supports in developing and carrying out the recovery plan whenever possible. Care coordination services are time limited, with a median of about 18 months duration, although the amount of time people require these services varies a great deal. The goal of care coordination services is to help the person establish network of services and supports that are aligned with their recovery vision and that can be relied on. When the person is sufficiently connected to such a support team, transition from care coordination services begins.
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Intensive and Supportive Case Management (ICM and SCM)
Care coordinators who provide ICM level services assist individuals with a diagnosis of serious mental illness in their recovery process with a minimum of four direct contacts a month. Individuals frequently in need of emergency services or hospitalization to assist in the management of mental health needs would most likely enroll at the ICM level.
Care coordinators providing service at the SCM level provide similar services but have a lower frequency of contact, with a minimum of two direct contacts per month. Individuals who are living in the community without the need for frequent crisis services but are struggling significantly to manage or make progress in their pursuit of the quality of life they desire, would most likely enroll at the SCM level.
Although individuals are assigned to a primary care coordinator’s caseload, all care coordinators work together in teams. This allows for continuous service when a care coordinator is out and also promotes flexibility in addressing individuals’ needs.
Supervisors for ICM and SCM programs:
Nancy White, LCSW
Marty Gosh, MA
Tom Nettle, MS
Jennifer Kelley, MSW
Forensic Case Management (FCM)
Services are provided to inmates, with a psychiatric disorder, who are transitioning into the community following incarceration at one of Onondaga County’s correctional facilities. This program is designed to be shorter term to allow the program to be available to enroll people as they are released.
Individuals with a need and interest in receiving continued care coordination services to pursue additional progress beyond a successful transition to community living can be transferred to either the ICM or SCM program.
Supervisor for Forensic program:
Marty Gosh, MA
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•18 years of age or older
•Serious and persistent
psychiatric disorder (i.e. Major
Depressive Disorder, Bipolar
Disorder, Schizophrenia,
Schizoaffective Disorder)
•Significant functional
impairments related to
daily living skills, personal
safety, community living,
economic self-sufficiency,
and/or use/engagement with
medical ormental health
services
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