Community-Based Services (CBS) are types of person-centered care delivered in the home and community. A variety of health and human services can be provided along with mental health and other medical care. These services are generally designed to increase access and address more complex health conditions. They may also provide more immediate access to care in the underserved communities. For many of the services, certain criteria may be required, for example income level, types or level of chronic conditions, Medicaid-eligibility, referrals, and residence. Fees vary depending on insurance coverage or Medicaid or Medicare eligibility. Many programs, however, offer a sliding-scale (based on your income) or assist with enrollment in Medicaid or other insurances.
A ´Health Home´ is not a physical place; it is a group of health care and service providers working together to make sure you get the care and services you need to stay healthy. Once you are enrolled in a Health Home, you will have a care manager that works with you to develop a care plan. A care plan maps out the services you need, to put you on the road to better health. Some of the services may include:
- Connecting to health care providers,
- Connecting to mental health and substance abuse providers,
- Connecting to needed medications,
- Help with housing,
- Social services (such as food, benefits, and transportation) or,
- Other community programs that can support and assist you.
In order to be eligible for Health Home services, the individual must be enrolled in Medicaid and must have:
- Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes*) OR
- One single qualifying chronic condition: HIV/AIDS OR
- Serious Mental Illness (SMI) (Adults) OR
- Serious Emotional Disturbance (SED) or Complex Trauma (Children)
If an individual has HIV or SMI, they do not have to be determined to be at risk of another condition to be eligible for Health Home services. Substance use disorders (SUDS) are considered chronic conditions and do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition to qualify. In addition, the Medicaid member must be appropriate for the intensive level of care management services provided by the Health Home (i.e., satisfy the appropriateness criteria).
How to enroll:
You can talk to your Managed Care Plan, doctor, specialist, hospital emergency room, discharge planner or your Department of Social Services, or contact one of the following:
Health Home Resources
Health and Recovery Plans (HARPs)
These plans will manage care for adults with significant behavioral health needs. They will facilitate the integration of physical health, mental health, and substance use services for individuals requiring specialized approaches, expertise and protocols which are not consistently found within most medical plans. In addition to the services offered by mainstream managed care, qualified HARPs will offer access to an enhanced benefit package comprised of Home and Community Based Services (HCBS). Individuals currently enrolled in HIV Special Needs Plans (HIV SNPs) meeting the serious mental illness (SMI) and substance use disorder (SUD) targeting criteria and risk factors for HARP will also be eligible to receive HCBS while enrolled in their HIV SNP.
All individuals enrolled in HARPs and those in HIV SNPs meeting the SMI and SUD targeting criteria and risk factors for HARP will be offered Health Home care management services. Eligibility for HCBS is determined through an assessment and referral from a Health Home or other mental health or medical provider.
Many agencies offer HARP programs, but a referral by a mental health professional is needed. You can work with your provider to find a program.
Home and Community Based Services (HCBS) – Behavioral Health
Home and Community Based Services for behavioral health (BH HCBS) will be available to adults enrolled in a HARP or HIV SNPs and who meet eligibility as determined through assessment. These HCBS services are recovery-oriented and designed to assist individuals with significant behavioral health needs living in the community. BH HCBS for eligible adults include the following:
- Psychosocial Rehabilitation
- Community Psychiatric Support and Treatment (CPST)
- Habilitation Services
- Family Support and Training
- Short-Term Crisis Respite
- Intensive Crisis Respite
- Education Support Services
- Peer Support Services
- Non-medical Transportation
- Pre-vocational Services
- Transitional Employment
- Intensive Supported Employment
- On-going Supported Employment
Many agencies offer HCBS programs, but a referral by a mental health professional is needed. You can work with your provider to find a program.
Single Point of Access (SPOA)
The Adult Single Point of Access (SPOA) provides timely access to intensive community-based Care Management, Assertive Community Treatment (ACT), and/or Housing Services and supports for adults with severe mental illness. Care Management, ACT, and/or Housing services are intended for individuals who are at high risk of further system penetration, who are unable to maintain community-based linkages and important supports such as psychiatric treatment and medication management, medical provider and treatment, housing & housing crisis management, substance abuse treatment, financial, social supports and legal assistance. (Taken from Erie County Office of Mental Health website).
SPOA has established a uniform referral procedure which helps determine the appropriate level of care coordination services and the team which best fits the needs of the individual. Referrals to the appropriate services are made by contacting Erie County SPOA.
Single Point of Access (SPOA) Resources
Assertive Community Treatment (ACT) Program
ACT teams assess the person’s current status and needs, develop individual service plans, monitor and reassess needs on an ongoing basis and respond to crisis situations and provide direct treatment and rehabilitation services. They serve individuals who are diagnosed with a serious mental illness and whose needs are not met by more traditional services. Staff work with an array of community organizations and are on call 24 hours a day, 7 days a week. Services are provided at any community location at which the consumer is willing to meet. All referrals must be made online to SPOA at: https://familyfirst.force.com/spoa/spoa2_home
Assertive Community Treatment (ACT) Resources
Assisted Outpatient Treatment (AOT)
Erie County administers the Assisted Outpatient Treatment (AOT) program, legislated by NYS as Kendra’s Law (https://omh.ny.gov/omhweb/kendra_web/khome.htm). This court-ordered program involves monitored behavioral health services. Services are provided to individuals with a mental illness who, in view of their treatment history and present circumstances, are unlikely to survive safely in the community without supervision.
Who may be eligible for AOT?
A person may be eligible to obtain AOT if he or she is:
- At least 18 years of age and suffers from a mental illness
- Is unlikely to survive in the community without supervision, based on a clinical determination
- Has a history of non-compliance with treatment for mental illness which has led to either 2 hospitalizations for mental illness in the preceding 3 years, or resulted in at least 1 act of violence towards self or others, or threats of serious physical harm to self or others within the preceding 4 years and is unlikely to accept treatment recommended in the treatment plan
- In need of AOT to avoid relapse or deterioration that would likely result in serious harm to self or others and will likely benefit from AOT.
Treatment can be court ordered; however, before a court will order AOT, it must be satisfied that AOT is the least restrictive alternative for the person. If a less restrictive program of treatment exists that could effectively deal with a person’s mental illness and needs, it will be the first option. In this case a diversion plan will be developed.
A diversion plan is a voluntary agreement of involvement in treatment by the consumer that precludes the need for court proceedings. The goal is to achieve and maintain stability through linkage with the most effective and least restrictive services available.
To achieve this goal, Erie County Department of Mental Health has designated Assertive Community Treatment teams to coordinate and/or deliver AOT services consistent with an Individualized Service Plan.
What is the process for obtaining AOT for someone?
Contact the Erie County Department of Mental Health’s AOT program at 716-858-2893. Appropriate staff will respond to your concerns and questions while gathering information about the referral. Screening will determine eligibility and referral to an appropriate team.
When does the Court system become involved in the process?
After diligent efforts have been exhausted and a consumer remains at risk, a petition will be initiated to ensure safety and treatment compliance. The petition, which is a formal statement of facts demonstrating that the person meets criteria for AOT, must be accompanied by the affidavit of an examining physician. The affidavit must show that the physician examined the person and developed a treatment plan prior to filing a petition, and that the consumer meets the criteria. A court hearing takes place involving physician testimony and, at times, testimony of significant others.
Who provides the services?
Designated mental health agencies provide AOT teams. Since assignment to AOT must go through Erie County SPOA, these agencies are not listed here. Providers included in Adult Treatment resources generally list this service (as AOT) in their service descriptions.
Assisted Outpatient Treatment (AOT) Resources
Medication Grant Program
The Medication Grant Program (MGP) was developed as part of Kendra’s Law (Assisted Outpatient Treatment-AOT). The program is run by the Erie County Department of Mental Health, and is for individuals who require psychiatric medications at discharge from Article 28 hospitals (ECMC-Erie County Medical Center, or Lake Shore Health Care Center) or a county correctional setting (Erie County Holding Center or Erie County Correctional Facility), or a prison. Requirements are that an individual is receiving case management/care coordination services to assist in application for Medicaid which must occur within 7 days of discharge from the hospital, jail or prison.
Mobile Support Programs
100 River Rock Drive – Suite 300
Buffalo, New York 14207
Emergency Mental Health Response Services can assist with individuals who are currently experiencing, or have recently experienced, a mental health crisis.
- Mobile Outreach Program/Crisis Services
- Mobile Transitional Support (MTS)/Crisis Services
Intake: Through responding staff at the main number
- CIT-Crisis Case Management Program
VA Western New York Healthcare System
Mobile Outreach Team (MOT)
Pager # 716-460-0152
Recovery Services & Rehabilitation/Day Treatment
Recovery and rehabilitation outpatient services may be offered through a Personalized Recovery Oriented Services (PROS) program, day treatment or partial hospitalization programs as well as other programs. Treatment focuses on self-management, securing and maintaining friendships, participating in a family group, and constructive use of community services as well as psychiatric clinical services. Services focus in areas of vocational, leisure, adult daily living skills and social needs; educational and skill training, prevocational and vocational training as appropriate; referral and linkage to other community resources. Services may include Community Rehabilitation and Support Services (CRSS), Intensive Rehabilitation (IR), Ongoing Rehabilitation and Support (ORS), clinical treatment, an Individualized Recovery Plan (IRP), or Individualized Service Plan (ISP). You may find more information at www.carecoordination.org.
PROS (Personalized Recovery Oriented Services) program is designed for individuals requiring less supervision than that provided in a hospital, but in need of services more structured and intensive than those offered in clinic treatment programs. It is an intensive rehabilitation program that focuses on helping individuals with one or more serious mental illnesses manage their symptoms effectively while also teaching them life skills.
Providers will emphasize different activities, and may be more or less focused on self-determination and supporting personal goals. Some may be more flexible in responding to an individual’s requests and needs. If your family member is unhappy with one particular program, he/she may want to try another one with a different level of service.
Recovery & Rehabilitation Resources
BestSelf Behavioral Health, Inc.
255 Delaware Ave
Buffalo, NY 14202
Community Health Centers
A Community Health Center (Federally Qualified Community Health Center or FQHC or CHC) is a primary care center that is community-based and patient-centered. It serves those with limited access to health care although all are welcome. Behavioral health services are available for evaluation counseling services. Individuals with more serious mental illness will be linked to other mental health providers as appropriate.
A CHC welcomes low income individuals, the uninsured and underserved. You pay what you can afford, based on your income. It provides a range of services including adult and pediatric care, primary and preventive care, behavioral health services, dental care and substance abuse services in a culturally and linguistically appropriate setting. Transportation assistance and multiple languages are also offered.
Community Health Center Resources
- Broadway Clinic
Buffalo, NY 14212
- NHC – Mattina
300 Niagara Street
Buffalo, NY 14201
155 Elmview Avenue
Hamburg, NY 14075
4233 Lake Avenue
Blasdell, NY 14219