May 2018 – Care Coordination

Care Coordination is a program within the Division of Clinical and Rehabilitation. Care Coordination is a care management agency overseen by Hudson River Healthcare, which is a NY state Health Home. A Health Home is not a physical space. It is a group of health and community agencies that work together to help Medicaid eligible adults with serious and chronic health conditions. Care  Coordination assists clients with obtaining the healthcare they need to stay healthy and independent in the community.

Care Coordination currently serves 340 adults in Columbia and Greene Counties. To be eligible for Care Coordination services, an adult has to be Medicaid eligible with a serious mental illness or two chronic health conditions.

Care Coordination is a team of 11 staff who develop relationships with a multitude of providers that can help clients build connections to a community of wellness. This program assists clients in organizing their health care activities in order for them to receive the most appropriate and best services available.  Care Coordinators help clients with: making and remembering appointments, setting up transportation to appointments, communicating with providers, answering questions about healthcare, finding new providers, advocating for services, linking and referring to community resources and more.

Over the past year, Care Coordination has expanded outreach activities. We have two Outreach and Enrollment Care Coordinators who rotate through various agencies to enroll clients into our program or link them to other needed services.

You can find an Outreach Care Coordinator at:

Columbia Memorial Hospital Emergency Department on Thursdays from 1pm to 4pm

Columbia Memorial Psychiatric Department on the 4th Wednesday of the month

Columbia County Department of Social Services on the 2nd Tuesday of the month to meet with homeless adults

The monthly Columbia County Probation panel to meet adults newly on probation

In the future we will be expanding our outreach efforts to Reentry programs and Primary Care offices. Care Coordinators are certified NYS HARP Assessors. One essential role Care Coordination has played in the last year is linking HARP enrolled clients to Home and Community Bases Services (HCBS).

If you or anyone you work with would like to learn more about Care Coordination or enroll in Care Coordination, please feel free to contact myself, Jacklyn Perez at or 518-943-2591.

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