Young woman and elderly woman sitting in her living room looking at paperwork

Nursing Home Transition and Diversion Service Coordination

Nursing Home Transition and Diversion Service Coordinators have been supporting Nursing Home-eligible individuals as one Service Coordination agency under the Department of Health’s Nursing Home Transition and Diversion Waiver since 2008, service coordinators work in partnership with the individual to ensure that they receive the most appropriate supports based on their need to help them remain integrated in their home and community.

Nursing Home Transition and Diversion Service Coordination

Pathways, Inc. Nursing Home Transition and Diversion (NHTD) Service Coordinators have been supporting Nursing Home-eligible individuals as one Service Coordination agency under the Department of Health’s Nursing Home Transition and Diversion program since 2008. The NHTD Service Coordinators work in partnership with the individual to ensure that they receive the most appropriate supports based on their need to help them remain integrated in their home and community.

Services Provided

  • Focuses on keeping you in your home in the community
  • Assists in moving you from the nursing home environment to your home in the community
  • Meets with you in your home
  • Provides education on available services and resources for various physical/medical diagnoses
  • Promotes choice
  • Secures needed assessments to maintain eligibility for services
  • Assists in obtaining and maintaining benefits and entitlements (Medicaid, Medicare, Food Stamps)
  • Links to doctors, specialists, day services, transportation, and in-home personal care supports

Population and Geographic Area Served

The Nursing Home Transition and Diversion (NHTD) Service Coordination program supports individuals in Broome, Chemung, Schuyler, Steuben, Tioga, and Tompkins counties under the guidance of the Department of Health’s NHTD Waiver. Individuals must be at least 18 years old, Medicaid-eligible, and have a documented physical or medical diagnosis.

Access to Services

You can contact us at any time to learn more about the NHTD Waiver and to determine if we are the Service Coordination Agency you would like to work with. If deemed eligible for the program, we will connect you with the regional office for intake to the NHTD Waiver.

Contact

Pathways Inc. NHTD Service Coordination can help you or a loved one secure the supports and services necessary to foster continued life in the community. For more information, contact:

Service Coordination Supervisor

Pathways, Inc.
800 West Broad Street, Horseheads, New York 14845
T: (607) 442-4392  F: (607) 937-3208

Care Coordination

These services provide care coordination to youth and adults with chronic medical conditions to get the care they need to improve their health and supports. Additionally, these services provide service coordination for adults that are Nursing Home-eligible or have traumatic brain injuries. Pathways, Inc. also provides contracted services with the Steuben Department of Social Services, Steuben County Community Mental Health Services for adults and children, Chemung County Safe Zones, Chemung County Skill Building, Steuben County Public Health, and Monroe County Skill Building.

Adult Care Management

Through Adult Care Management, a Care Manager partners with adults to get the care they want to improve their physical, behavioral, and social health and supports.

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Children's Care Management

Through Children’s Care Management, a Care Manager helps youth and caregivers get the services they need to improve the youth’s health.

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High Fidelity Wraparound

High Fidelity Wraparound is a national, evidence-based process that focuses on the goals of the family to address complex emotional and behavioral needs of the youth.

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Monroe County Skill Building

Skill Builders increase success of youth with mental health needs in the community through individual services in the home or community. These weekly services will help overcome barriers in functioning and interpersonal relationships to decrease behavioral needs.

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Nursing Home Transition and Diversion Service Coordination

Nursing Home Transition and Diversion Service Coordinators have been supporting Nursing Home-eligible individuals as one Service Coordination agency under the Department of Health’s Nursing Home Transition and Diversion Waiver since 2008, service coordinators work in partnership with the individual to ensure that they receive the most appropriate supports based on their need to help them remain integrated in their home and community.

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Recovery Coordination

Through this Recovery Coordination Agency (RCA), a Recovery Coordinator assists adults with Managed Care to gain peers and partners in the community.

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Steuben County Department of Social Services Collaborative Programs

Steuben County Department of Social Services (DSS) Collaborative Programs serve children who are at imminent risk of out-of-home placement and their families.

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Traumatic Brain Injury Service Coordination

Traumatic Brain Injury (Traumatic Brain Injury) Service Coordinators have been supporting individuals with TBI as one Service Coordination agency through the Department of Health’s TBI Waiver program since 1995, and work in partnership with the individual to secure supports and services that will allow them to live as independently and productively as possible.

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