Community-Based Services
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.
Health Homes
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.
Eligibility:
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
Best Self Health Home Services
Health Homes of Upstate New York (HHUNY)
1-855-613-7659
www.hhuny.org
Covers WNY; HHUNY also serves the Finger Lakes, Southern Tier and Central New York
Health Home Partners of WNY, LLC
716-566-4100 or 800-466-2040
Care Manager Organizations: Spectrum Health, Catholic Health Systems, Evergreen
Covers Erie, Niagara & Wyoming Counties
http://www.healthhomewny.com/
Greater Buffalo United Accountable
Healthcare Network (GBUAHN)
716-247-5282
564 Niagara Street, Building 2
Buffalo, NY 14201
www.gbuahn
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
Adult Single Point of Access (SPOA)
Erie County Department of Mental Health
716-858-8096
Fax: 716-858-7558
95 Franklin Street, Room 1237
Buffalo NY 14202
For referral: https://familyfirst.secure.force.com/spoa2_home
SPOA Practitioner
716-439-7527
Fax: 716-439-7418
Niagara County Department of Mental Health
5467 Upper Mountain Road, Ste. 200
Lockport, NY 14094-1895
www.niagaracounty.com
SPOA offices in other WNY counties can be found by calling 2-1-1, or visit www.211wny.org
Service Details
Supportive or subsidized housing may be difficult to qualify for due to a shortage of this type of housing in WNY. Although an individual may self-refer by applying online at the SPOA website, a referral from a mental health provider is usually required. See more in the Support & Other Resources – Housing section.
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
Buffalo Psychiatric Center/ACT Team
716-816-2935
Butler Rehabilitation Center
400 Forest Ave
Buffalo, NY 14213
www.omh.ny.gov/omhweb/facilities/bupc/
Service Details
Services may include coordination of treatment, medication management, advocacy, linkage and monitoring for the chronically ill, those with dual diagnosis, or those suffering from trauma. This service replaces linkage with an outpatient clinic.
BestSelf Behavioral Health/ACT Team
716-884-0888
255 Delaware Ave
Buffalo, NY 14202
www.BestSelfwny.org
Service Details
Fully mobile teams of mental health professionals providing a range of community based treatment and rehabilitation services to persons with serious and persistent mental illness.
Spectrum Health & Human Services /ACT Team
716-842-6713
1280 Main Street
Buffalo, NY 14209
www.shswny.org
Service Details
In-home and community based services which may include housing assistance, money management, work assessment and training, medication management and more.
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
Erie County Department of Mental Health
Assisted Outpatient Treatment (AOT) Program
716-858-2893
Fax: 716-858-7558
95 Franklin St., Rm. 1237
Buffalo, NY 14202
Contact: Lisa McNeil 716-858-7059
-or- Jennifer Levesque 716-858-2893
Service Details
For individuals who meet specific criteria under Kendra’s Law, who may need mandated services where other alternatives have been diligently attempted.
AOT/Niagara County
716-285-3518
1000 Eleventh St
Niagara Falls, NY 14301
www.niagaracounty.com
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
Crisis Services
716-834-3131
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
716-834-3131
Service Details
The Mobile Outreach Program is the mobile unit of Erie County Medical Center’s Comprehensive Psychiatric Emergency Program (CPEP). This program provides community-based mental health intervention to individuals in Erie County who are experiencing a mental health crisis. The main goal of the program is to divert individuals from unnecessary presentations at local psychiatric emergency rooms and to provide these individuals the services they need in order to remain safely in the community. Services are available 24 hours a day by calling 716-834-3131 and asking for an Outreach Counselor.
- Mobile Transitional Support (MTS)/Crisis Services
716-834-3131
http://crisisservices.org/mental-health/#mobiletransitional
Intake: Through responding staff at the main number
Service Details
A 24/7 service for approximately 3 months through Crisis Services, funded by Erie County. MTS provides intensive support following discharge from inpatient psychiatric care. Team includes a nurse, social worker, and peer support advocate to help the individual remain stable and connect with providers specified in the follow-up plan. The team can address logistics like transportation and other barriers to follow-through. This program must be accessed through the discharge planner at either ECMC or the Buffalo Psychiatric Center. Family or individual may request the program through the discharge planner, or if needed, through the MTS staff at Crisis Services.
- CIT-Crisis Case Management Program
Service Details
This program provides short-term crisis case management services to individuals with mental illness who interface regularly with law enforcement. Individuals must live in towns/jurisdictions whose police agency has a trained CIT team. Most referrals to this program come from CIT Officers, but referrals from other sources can be considered if the individual otherwise meets program criteria. The goal of CIT-Crisis Case Management is to decrease interactions with law enforcement and increase linkages with mental health services in the community, as well as diversion (when appropriate) from local psychiatric emergency rooms and jail. For more information on CIT, click here.
Mobile Integration Team (MIT)/Buffalo Psychiatric Center
716-885-2261
400 Forest Ave
Buffalo, NY 14213
www.omh.ny.gov/omhweb/facilities/bupc/
Service Details
Provides clinical intervention and support necessary for adults with serious mental illness to not only remain in the community, but also continue moving forward in recovery. A multidisciplinary team, including peers dedicated to partnering with people with mental illness and their families to keep them healthy while living in their communities.
Mobile Mental Health Services/
BestSelf Behavioral Health, Inc.
716-884-0888
255 Delaware Ave
Buffalo, NY 14202
www.bestselfwny.org
Service Details
Counseling provided in the community and in-home for Medicaid recipients who have significant barriers to receiving outpatient treatment.
VA Western New York Healthcare System
Mobile Outreach Team (MOT)
Pager # 716-460-0152
Service Details
Non-emergency outreach service to disengaged and/or at risk veterans. Continued efforts to reach veterans who are homeless or at high risk of homelessness.
*Dial the pager # and after the tone, enter your phone #. You will usually receive a call back within a day, though response may be longer on weekends. If an emergency call 911 or Crisis Services (835-3131).
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.
PROS Program
716-884-0888
255 Delaware Ave
Buffalo, NY 14202
https://www.bestselfwny.org/personalized-recovery-oriented-services-pros/
Service Details
A mobile outreach team targeting psychiatrically disabled adults temporarily living in homeless shelters or who are homeless. Provides intensive clinical case management, supportive counseling, crisis intervention, advocacy, and assistance in obtaining permanent housing and appropriate mental health services. Focus on “Housing First,” followed by links to other needed medical and community services.
Buffalo Psychiatric Center (BPC)
GOALS Center
716-851-1297
ECC City Campus
45 Oak St., Rm. 141
Buffalo, NY 14203
www.omh.ny.gov/omhweb/facilities/bupc
Service Details
Intensive Psychiatric Rehabilitation Treatment (IPRT) program. A career/life development program for recipients in a structured rehab program that may include preparation for college or work.
Community Missions of Niagara Frontier
Niagara Visions PROS
716-205-8708
418 Third St
Niagara Falls, NY 14302
https://www.communitymissions.org/pros
Fees: Medicaid, Medicare, private pay, sliding scale.
Service Details
Comprehensive recovery-oriented day program. Supports goals directed by the individual and integrates treatment, support, and rehabilitation to facilitate recovery. Community Rehabilitation & Support (CRS), Intensive Rehabilitation (IR) services, Ongoing Rehabilitation & Support (ORS) services, Clinic Treatment.
Erie County Medical Center (ECMC)
Partial Hospitalization Mental Health Program
716-898-5569
462 Grider St
Buffalo, NY 14215
www.ecmc.edu See “Behavioral Health”
Fees: All insurances, sliding fees based on ability to pay.
Intensive outpatient program, 2-3 weeks duration.
Endeavor
PROS Program
716-896-7350
1131 Broadway
Buffalo, NY 14212
https://www.ehsny.org/services/adult-services/
Envision Wellness WNY
Day Treatment
716-871-7092
406 Vulcan St
Buffalo, NY 14207
https://www.envisionwellnesswny.com/services/
Service Details
Day Treatment program. Also has mental health clinic and outpatient co-occurring population services.
Northwest Community Mental Health Center
716-882-5959
1300 Niagara St
Buffalo, NY 14213
www.northwestcmhc.org
Continuing day treatment program for adults and seniors.
Service Details
The Emergency Housing Service provides short term (30 day) housing for individuals with psychiatric disorder who lack housing or funds for housing. Applicants must have a current psychiatric assessment from Erie County Medical Center (ECMC), Veterans Hospital, Buffalo Psychiatric Center, or any outpatient program.
Spectrum Health & Human Services, Inc.
PROS Program
716-662-2040
227 Thorn Ave
Orchard Park, NY 14127
https://shswny.org/services/pros/
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
Community Health Center of Buffalo (CHCB)
716-986-9199
462 Grider St
Buffalo, NY 14215-3021
www.Chcb.Net
Fees: Most insurances, sliding scale available
Service Details
CHCB provides a range of services including primary and preventive care, behavioral health services, dental care and substance abuse services in a culturally and linguistically appropriate setting.
Jericho Road Community Health Center
716-881-6191
184 Barton Street
Buffalo, NY 14213
www.jrchc.org/
Community Health Center offering comprehensive health and social services. Multiple languages.
OTHER LOCATION:
- Broadway Clinic
716-529-3020
1021 Broadway
Buffalo, NY 14212
Neighborhood Health Center
716-875-2904
155 Lawn Avenue
Buffalo, NY 14207-1816
www.neighborhoodhealthcenter.org
Community Health Center offering comprehensive health and social services. Multiple languages.
LOCATIONS:
- NHC – Mattina
716-242-8600
300 Niagara Street
Buffalo, NY 14201
- Southtowns
716-648-4345
155 Elmview Avenue
Hamburg, NY 14075
- Blasdell
716-332-3070
4233 Lake Avenue
Blasdell, NY 14219