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Case Management For People With Intellectual & Developmental Disabilities
GETTING STARTED WITH SOUTHERN TIER CONNECT
For an overview of our services, please visit our About page.
Eligibility Survey For People With IDD
Take our online survey to find out if you qualify!
Common Questions
WHAT IS CARE COORDINATION?
Care Coordination is built on a foundation of successful Medicaid Service Coordination by the region’s leading service providers who will now provide comprehensive care management. This means your care coordinator will connect you with the region’s very best service providers, linking together healthcare needs, transitional, behavioral, social and community services, and individual and family supports into one comprehensive plan. A plan that will change as your needs change, that will be supported by the use of creative technology to connect you to service providers across our rural area, and backed by our commitment to fiscal responsibility.
HOW DO I RECEIVE CARE COORDINATION THROUGH SOUTHERN TIER CONNECT?
If you feel like Southern Tier Connect is a resource that you or a loved one needs, you might find yourself in one of the following scenarios:
You have a child, or you are an individual who has just been diagnosed with a disability and doesn’t know where to start. The first step is The OPWDD Front Door. From this website, you can obtain contact information for all four OPWDD regions that Southern Tier Connect serves. More information about this process and a wealth of additional resources are available on OPWDD’s website. If you would like to speak with someone at Southern Tier Connect for further information about this process, please call our intake referral line at (607) 376-7526 x100 between the hours of 8-4 pm Monday-Friday.
You have been told by someone at OPWDD’s “Front Door” to look into the different CCOs in the area and would like some more information about us. Southern Tier Connect is unique- our approach focuses on our rural communities in 14 counties with resources spread far and wide. It is our privilege to connect the very best support to our clients. We will help facilitate your post-enrollment process with Southern Tier Connect. Call our intake referral line at (607)376- 7526 x110 or send us an email at intake@southerntierconnect.org. We can help you through the eligibility process and provide a coordinated assessment called the IAM Assessment which will help determine the types of services and goals you or the person in your care would like to achieve both long and short-term. We will provide you with assistance through the entire process and once deemed eligible for services. Our Care Coordination Managers (or CCMS) will work with you on an ongoing monthly basis to make sure your needs are being met in all areas of your life so you can be the most healthy, happy, and independent person you can and want to be!
You or someone in your care is already eligible for OPWDD (Office of People With Developmental Disabilities) Services and are interested in switching their CCO (Care Coordination Organization). If you would like to make the switch to Southern Tier Connect, please contact our intake referral line at (607) 376-7526 x110 or email intake@southerntierconnect.org to begin the process of joining Southern Tier Connect!
The Six Core CCO Services
1. COMPREHENSIVE CARE MANAGEMENT
- Completing a comprehensive health assessment/reassessment which includes medical, behavioral, rehabilitative, long-term care, and social service needs.
- Completing/revising an individualized person-centered plan of care with the Member to identify the Member’s needs/goals and include the Member’s family and social supports as appropriate.
- Consulting with multidisciplinary team on Member’s Care Plan/Needs/Goals
- Consulting with Primary Care Physician or any Specialists involved in Care Plan.
- Contact with Member to assess on-going emerging needs and promote continuity of care and improve health outcomes.
- Preparing a client Crisis Intervention/Management Plan
2. CARE COORDINATION AND HEALTH PROMOTION
- Coordinating with Service Providers and Health Plans as appropriate to secure necessary care, share crisis intervention and emergency information.
- Linking/referring members to needed services to support care plan/treatment goals, including medical/behavioral health care, patient education, and self-help/recovery and self-management.
- Conducting case reviews with an interdisciplinary team to monitor and evaluate member status/service needs.
- Advocating for services and assisting with scheduling of needed services.
- Coordinating with treating clinicians to ensure services are provided and to ensure changes in treatment or medical conditions are addressed.
- Monitor, support, or accompany the Member to scheduled medical appointments.
- Crisis intervention, revising care plan/goals required.
3. COMPREHENSIVE TRANSITIONAL CARE
- Following up with hospitals/ER upon notification of a member’s admission and/or discharge to/from an ER, hospital, residential or rehabilitative setting.
- Facilitating discharge planning from an ER, hospital, residential or rehabilitative setting to ensure safe transition/discharge to where care needs are in place.
- Notifying/consulting with treating clinicians, scheduling follow-up appointments, and assisting with medication reconciliation.
- Linking members with community supports to assure that needed services are provided.
- Following up post-discharge with member/family to assist member care plan needs/goals.
4. MEMBER & FAMILY SUPPORT
- Developing/reviewing/revising the individual’s plan of care with the member/family to ensure that the plan reflects the individual’s preferences, education, and support for self-management.
- Consulting with member/family/caretaker on advanced directives and educate on member rights and health care issues, as needed.
- Meeting with the member and family, inviting any other providers to facilitate needed interpretation services.
- Refer member/family to peer supports, support groups, social services, entitlement programs as needed.
- Collaborating/coordinating with community-based providers to support effective utilization of services based on member/family need.
5. REFERRAL, COMMUNITY, AND SOCIAL SUPPORT SERVICES
- Identifying resources/linking the member with community supports as needed.
- Collaborating/coordinating with community-based providers to support the utilization of services based on member/family needs.
- Service contact may be face-to-face, phone, mail, or electronic media contact. Contact must be a two-way exchange. Mailed information or messages are not complete contacts unless the member makes return contact as a result. Service contact may be with the member or any collateral identified on the member’s if a collateral contact is completed, CCM must still attempt to make contact with the member to inform/update on the progress of actions taken on their behalf.
6. THE USE OF HIT TO LINK SERVICES, AS FEASIBLE AND APPROPRIATE
- CCO/HH has structured information systems, policies, procedures, and practices to electronically create, document, execute, and update a Life Plan for every enrollee.
- CCO/HH has a systematic process to follow-up on tests, treatments, services and referrals, which is incorporated into the enrollee’s Life Plan.
- CCO/HH has an electronic record system which allows the enrollee’s health information and Life Plan to be accessible to the interdisciplinary team of providers and which allows for population management and identification of gaps in care including preventive services.
- CCO/HH makes use of available HIT and accesses data through the RHIO/QEs to conduct these processes, as feasible.
Helpful Documents & Links
First Step NY
Do you think your child may have an I/DD and don’t know where to start for a diagnosis? First Step is a leading Early Intervention agency that has successfully helped thousands of New York families to gain confidence in their children’s future. Their experienced staff provide the full scope of early intervention services which effectively address the needs of infants and toddlers with developmental delays or disabilities. The services are made available through federal law and focus on physical development, cognitive development, communication, social or emotional development, and adaptive development.
CAS / I AM Assessments
This chart explains the differences between the Coordinated Assessment System (CAS) and the I AM Assessment.
Children’s Waiver vs. OPWDD Waiver
This document gives an overview of the fundamental differences between the Children’s Waiver and the OPWDD Waiver (for adults).
More information can be found on the NYS DOH website:
New Enrollment Intake Process
The intake process will take differing amounts of time based on individual circumstances. Click below for a PDF flowchart of the process.
OPWDD Front Door
The Front Door is the way OPWDD connects you to the services you want and need. Once you enter, a person-centered planning process begins, which helps you learn about and access service options that take your needs and desires into consideration. It will also give you the chance to direct your own service plan or help your family member or loved one as they direct theirs.