Care coordination helps people connect with the services and supports they need to improve health, stability and quality of life. At Citizen Advocates, care coordination services are designed to help patients identify resources, overcome barriers and build the skills needed to manage care more independently over time.

Care coordinators can help you navigate medical care, behavioral health services, community supports and benefits, so your care feels organized, connected and easier to access.

Citizen Advocates offers two types of care coordination services:

• Targeted Case Managers (available at all six Citizen Advocates clinics)
• Health Home Care Coordinators (available at Outpatient clinics in Malone, Massena and Saranac Lake)

Targeted Case Managers

Targeted Case Managers provide care coordination support for individuals who are receiving services at any Citizen Advocates outpatient clinic or Behavioral Health Campus.

These services are designed to support needs that may fall outside of counseling or therapy sessions. Targeted Case Managers help patients address challenges that may affect treatment progress, daily functioning or overall stability.

How Targeted Case Managers Can Help

Targeted Case Managers may assist with:

• Connecting to community resources and support services
• Coordinating appointments and services
• Addressing practical barriers that interfere with treatment
• Helping patients build skills for planning, follow-through and self-advocacy

How to Request Services

Care coordination through a Targeted Case Manager can be requested through your therapist. If you are already receiving services at Citizen Advocates, your care team can help connect you.

Malone Behavioral Health Clinic Malone Phone:518-483-3261 Hours:Monday, Wednesday, Friday: 8 a.m.-5 p.m.; Tuesday, Thursday: 8 a.m.-7 p.m. (By appointment or walk-in) Location:31 Sixth Street, Malone, NY 12953

Malone Behavioral Health Campus Malone Phone:518-481-8160 Hours:24 hours/day, 7 days/week, 365 days/year Location:125 Finney Boulevard, Malone, NY 12953

Massena Behavioral Health Clinic Massena Phone:315-764-8076 Hours:Monday-Wednesday, Friday 8 a.m.-5 p.m.; Thursday 8 a.m.-7 p.m. (By appointment or walk-in) Location:16 Phillips Street, Massena NY, 13662

Ogdensburg Behavioral Health Campus Ogdensburg Phone:315-713-9090 Hours:24 hours/day, 7 days/week, 365 days/year Location:1003 Park Street, Ogdensburg, NY 13669

Saranac Lake Behavioral Health Clinic Saranac Lake Phone:518-891-5535 Hours:Tuesday, Wednesday, Friday: 8 a.m.-5 p.m.; Monday, Thursday: 8 a.m.-7 p.m. (By appointment or walk-in) Location:70 Edgewood Road, Saranac Lake, NY 12983

Watertown Behavioral Health Campus Watertown Phone:315-755-1251 Hours:24 hours/day, 7 days/week, 365 days/year Location:650 State Street, Watertown, NY 13601

Health Home Care Coordination (HHCC)

Health Home Care Coordination is a specialized form of care coordination for individuals who are managing complex needs across multiple areas, such as physical health, mental health, substance use and social challenges.

If you have Medicaid and are struggling to manage chronic conditions or multiple services, the Health Home program provides a dedicated care coordinator who helps ensure your care is connected, comprehensive and easier to navigate.

What Is Health Home Care Coordination?

Health Home Care Coordination is a Medicaid program that provides a personal care coordinator who can help you:

• Connect with comprehensive medical, social and behavioral healthcare services
• Ensure providers communicate effectively with each other, reducing confusion and duplicate services
• Get timely care in the most appropriate setting, preventing health issues from becoming emergencies
• Stay healthier at home through routine care and support, reducing emergency room visits and hospital stays
• Create and work toward meaningful health goals that matter to you

Health Home Care Coordination is available for both adults and children.

Eligibility Requirements for Health Home Care Coordination

To qualify, individuals must have:

• Active Medicaid, and
• One or more of the following:
  • Two or more chronic conditions
  • HIV/AIDS
  • Complex trauma
  • Serious emotional disturbance
• Significant behavioral, medical and/or social risk factors

If you are unsure whether you qualify, our team can help review eligibility and next steps.

Health Home Care Coordination Services

Health Home Care Coordinators can help individuals access and coordinate services such as:

Benefits and Financial Supports

• SNAP (Supplemental Nutrition Assistance Program)
• SSI (Supplemental Security Income)
• HUD (Housing and Urban Development)
• HEAP (Home Energy Assistance Program)
• And other benefit programs

Healthcare and Support Services

• Medical and behavioral health transportation
• Coordinated care across all providers
• Healthcare advocacy and support
• Social activities and community programs

Personalized Support

Health Home Care Coordinators also:

• Assess strengths and needs
• Develop personalized goals
• Connect individuals with resources
• Provide ongoing support over time

How to Request Health Home Care Coordination

Health Home Care Coordination services can be requested by:

• The individual
• A family member
• A service provider
• A therapist or Targeted Case Manager

Because Health Home Care Coordination is a voluntary program, the individual must agree to services before enrollment.

Andrea Palermo andreapalermo@citizenadvocates.net Phone:518 353-0052 Location:Franklin, Clinton, St. Lawrence, & Essex counties

Assisted Outpatient Treatment Care Coordination (AOT)

Citizen Advocates also offers an Assisted Outpatient Treatment (AOT) care coordinator for qualifying individuals. This form of care coordination may be authorized through a voluntary service agreement or through the direction of a court-ordered psychiatrist.

Individuals may qualify if they have:

• Two or more psychiatric hospital admissions and/or incarcerations, and
• These events relate to a risk of harming others

Related services

Peer Support Services

Peer support services connect individuals with trained peer support specialists who use lived experience to provide practical, non-clinical support for mental health and addiction recovery.

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Telehealth Services

Telehealth makes it easier to get the mental health and addiction services you need, no matter where you live.

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