Care Management Program
Mohawk Opportunities’ Care Management Program supports individuals with chronic medical and behavioral health conditions. Care Managers connect members with community resources to help them improve their health outcomes and achieve personal goals.
The program is designed to link individuals with needed services, including but not limited to:
Primary Care Providers
Medical Specialists
Outpatient Mental Health Services
Substance Abuse Services
Safe & Affordable Housing
Social Service Agencies and other community resources
Connecting individuals to critical services that are essential to their care and wellbeing.
After connecting a member with the necessary community resources, the Care Manager's role is to collaborate with providers in helping members attain positive physical, behavioral, and social health outcomes. The program caters to four different acuity levels: Assisted Outpatient Treatment, Health Home Plus, High Risk High Need, and regular Health Home populations.
Mohawk Opportunities is a specialized mental health care management agency. It has been recognized as a "High Performing Care Management Agency" by Community Health Connections, which is the Department of Health's designated Lead Health Home in Schenectady, Albany, and Rensselaer Counties. Community Health Connections provides oversight to the Mohawk Opportunities Care Management Program.
A Dedicated Team of Care Professionals
The Care Management Program consists of a Program Director with master’s level clinical experience, Two Assistant Program Directors, and Care Managers who directly support enrolled members. Additionally, Mohawk Opportunities provides an Outreach Care Manager and a Transitional Care Manager.
The Outreach Care Manager is assigned to the Schenectady HUB, assisting in the engagement and coordination of services for individuals who are street homeless as part of the. The Schenectady HUB is a unique collaboration between the Schenectady Police Department, the County Office of Community Services, and local agencies working together to provide outreach to people who are street homeless for the purpose of developing wrap-around services and permanent housing.
The Transitional Care Manager assists with coordinating individuals’ transition to the community from hospitals, incarceration, and other types of institutional care. The Care Manager assists with establishing benefits, finding a home, engaging in treatment, establishing primary medical care, etc., to support the individual’s successful integration into their community.
Program Enrollment
A Care Management referral can come from various sources, and community programs can send one directly to the program director. A member's family or a prospective member can self-refer by reaching out to the program director. Community Health Connections also provides downstream referrals to accepting agencies within its network.