Care Coordination

Care Coordination

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. The Care Manager helps connect individuals with health care providers and service providers to reach personalized health goals. You must have Medicaid, qualifying health condition(s), and have an unmet need to enroll in Adult Care Management, where you gain a Care Manager, the key point of contact in helping you manage your health needs. Pathways works in partnership with Circare, Huther Doyle, and Health Home of Upstate New York (HHUNY).

Contact Director, Care Coordination & Contract Management (607) 937-4520

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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. As part of the Health Home Care Management model, through CHHUNY, LLC, a care manager coordinates, advocates, and educates to support children and youth who are enrolled in Medicaid and have qualifying health conditions. When you enroll your child in Children's Care Management, you are not enrolling in a place–you are gaining a Care Manager, the key partner in helping you manage services for your child.

Contact Director, Care Coordination & Contract Management (607) 937-4520

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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. The High Fidelity Wraparound Care Manager partners with the family and facilitates the intensive process with the collaborative team, including natural supports and community providers, while honoring family voice. The team builds the family-specific strengths to get needs met, learn new skills, and develop skills and supports to manage crisis. This is a pilot program in Yates County made possible by NYS Systems of Care.

Contact Director, Care Coordination & Contract Management (607) 937-4520

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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.

Contact Director, Care Coordination & Contract Management (607) 937-4520

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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.

Contact Director, Care Coordination & Contract Management (607) 937-4520

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Recovery Coordination

Through this Recovery Coordination Agency (RCA), a Recovery Coordinator assists adults in Medicaid Managed Care to gain peers and partners in the community. By collaborating with individuals in the community, the Recovery Coordinator provides ongoing assessment and referral for Adult Behavioral Health Home and Community-Based Services (HCBS). Pathways, Inc. is an approved provider of HCBS. These services are for adults aged 21 and up who are Health and Recovery Plan (HARP) eligible with behavioral health needs such as serious mental illness and/or substance use disorder. The adult may decide to be referred for coordination services to assist with HCBS and other needs, or the Recovery Coordinator can continue to monitor HCBS involvement.

Contact Director, Care Coordination & Contract Management (607) 937-4520

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Traumatic Brain Injury Service Coordination

Pathways, Inc. Traumatic Brain Injury (TBI) Service Coordinators have been supporting individuals with TBI as one Service Coordination agency through the Department of Health’s TBI Waiver program since 1995. The TBI Service Coordinator works in partnership with the individual to secure supports and services that will allow them to live as independently and productively as possible while managing symptoms of TBI, including mild TBI/concussions.

Contact Director, Care Coordination & Contract Management (607) 937-4520

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Additional Services

Steuben County Department of Social Services Collaborative Programs

Family Interactions

Offers services in Steuben County to parents and their children in foster care with a goal of reuniting the family wherever possible.

Contact Family Interactions Coordinator (607) 776-1568

Family Preservation

Offers immediate, short term intensive services to families whose children are at imminent risk of placement in foster care.

Contact Family Preservation Coordinator (607) 776-2484

Youth WRAP Around Alternative

Provides intensive services for youth referred by the Steuben County Department of Social Services (DSS), and may be either preventative or transitional in order for the child to remain at home and be successful.

Contact Youth Services Coordinator (607) 776-7754

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