Assertive Community Treatment ( ACT)

Mohawk Opportunities Inc. Assertive Community Treatment Team, (ACT), Is an evidence based treatment program that utilizes a mobile, multidisciplinary team of staff to deliver flexible, comprehensive treatment, support and rehabilitation services to individuals residing in the community with a severe and persistent mental illness. The program is specifically designed to respond to the needs of individuals whose treatment history has been characterized by frequent use of psychiatric hospitalization and emergency rooms, a lack of engagement in or inability to benefit from traditional outpatient services, involvement in the criminal justice system and/or alcohol/substance abuse. The program’s goal is to help these individuals achieve stability within the community so that they are able to move forward with their recovery and return to a lower level of care.

Services offered by the program are intensive, non-traditional in nature and provided by a multidisciplinary team rather than an individual clinician. Clients are reviewed by the team each morning to assess and monitor current functioning and need. Frequency of contact is based on identified need with contacts most often occurring in the clients’ home or a community setting. Outreach is a key component of the service model.

The ACT team includes a Team Leader; a Psychiatrist; Registered Nurse; masters level Clinicians with specialties in substance abuse services, family services, and vocational services; and a Peer Specialist.

Services offered by the ACT team include:

• Comprehensive Assessment      • Service Planning and Coordination
• Individual Treatment •Medication Management
• Substance Abuse Treatment • Vocational Skills Training
• Family Counseling • Housing Supports
• Wellness Self Management • Money Management

All referrals to ACT team must be forwarded to and reviewed by the Schenectady County SPOA Coordinator. Once forwarded to the program by the SPOA Coordinator, all referrals are processed within 72 hours. 

To be eligible to receive services from the ACT team, individuals must meet the following criteria:

• 18 years of age or older.
• A severe and persistent mental illness that seriously impairs their functioning in the community.
• A history of a lack of engagement in or inability to benefit from traditional outpatient services.

Participation in ACT services is voluntary. 

No person shall be excluded from receiving ACT services based on race, religion, ethnicity, age, gender, sexual orientation, HIV status.

Dominion House

Dominion House in the Spring

Mohawk Opportunities Inc. Dominion House is a 12 bed crisis residence which provides short term support and housing to individuals with a severe and persistent mental illness.  Individuals referred to the program have experienced a crisis that has disrupted their stability in the community or are in the process of transitioning back to the community after a period of stay in a more intensive residential setting/hospital.  The goal of the program is to offer these individuals a safe, stable place to stay and provide them with necessary supports as they stabilize and prepare to transition to a more permanent community living situation.  Services offered focus on helping the individual gain/regain the skills and emotional stability needed to successfully reside in the community.  Program staff also work collaboratively with other service providers to ensure identified needs are addressed i.e. mental health or substance abuse treatment, health care, public assistance, etc.  An individualized service plan is developed with and for each client upon their entry into the program and is used to guide service delivery.

Participation in the program is voluntary and the average length of stay is 90 days.

Dominion House is staffed by a team of Residence Counselors, a Client Services Counselor/Case Manager, a Program Director and 2 Assistant Program Directors.  The program provides 24 hour awake staffing.

To be eligible for services from Dominion House, individuals must meet the following admission criteria:

• 18 years of age or older
• A primary diagnosis of a psychiatric illness.
• Not currently assessed as being dangerous to self or others or otherwise in need of hospitalization.
• Have a documented inability to live independently in the community.
• In adequate health so as not to require skilled nursing care.
• Voluntarily agree to comply with Mohawk Opportunities, Inc. Residency Agreement.
• Must demonstrate a willingness to assist in securing necessary funds to cover the cost of care and services.

All referrals to Dominion House must be forwarded to and reviewed by the Schenectady County SPOA Coordinator.  Once forwarded to the program by the SPOA Coordinator, all referrals are processed within 72 hours.  Emergency referral and placement is possible.

No person shall be excluded from admission to the program based on race, religion, ethnicity, age, gender, sexual orientation or HIV status.

Community Residence Program – Jones Home, Emmanuel House & Curry House

Mohawk Opportunities, Inc. operates three (3) New York State Office of Mental Health Certified Community Residences for individuals with a severe and persistent mental illness who have a continuing need for rehabilitative services. This level of programming is intended to respond to the needs of individuals who have demonstrated an ability to live in a community setting, but are not yet ready to live independently. The goal of each home is to provide residents with a safe, comfortable, supportive place to live as they continue their recovery and acquire the skills needed to achieve the highest level of independence possible. 

In addition to providing ongoing support and encouragement to each resident, program staff work closely with residents offering restorative services and skill building training in the following areas:

• Symptom Management • Rehabilitation Counseling
• Daily Living Skills • Socialization
• Budgeting • Vocational Skill Development.
• Health Services • Substance Abuse Services
• Medication Management • Parenting Training
• Assertiveness and Self Advocacy     • Community Integration

Program staff also work collaboratively with other community service providers to ensure identified needs are addressed i.e. mental health and or substance abuse treatment, health care, public assistance, etc. An individualized service plan is developed with and for each resident upon their entry into the program and is used to guide service delivery and to help prepare residents for transition to a more independent living situation. 

Each Community Residence is staffed by a team of Residence Counselors, a Program Director and an Assistant Program Directors. The program provides 24 hour staff availability. 

All referrals to our Community Residence Program must be forwarded to and reviewed by the Schenectady County SPOA Coordinator. Once forwarded to the program by the SPOA Coordinator, all referrals are processed within 72 hours. 

To be eligible for admission to a Community Residence, individuals must meet the following criteria:

• 18 years of age or older
• A primary diagnosis of a psychiatric illness.
• Not currently assessed as being dangerous to self or others or otherwise in need of hospitalization.
• Have a documented inability to live independently in the community.
• In adequate health so as not to require skilled nursing care.
• Voluntarily agree to comply with Mohawk Opportunities, Inc. Residency Agreement.
• Must demonstrate a willingness to assist in securing necessary funds to cover the cost of care and services.

Participation in the Community Residence Program is voluntary. 

No person shall be excluded from admission to a community residence based on race, religion, ethnicity, age, gender, sexual orientation or HIV status.

Certified Apartment Program

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Mohawk Opportunities’ Certified Apartment Program provides affordable housing, intensive skills training and ongoing support to individuals with a severe and persistent mental illness who have a continuing need for such services as they continue their journey towards living independently in the community. The program is intended to be transitional in nature and is designed to improve an individuals’ community living skills level to the point where they are able to move on to a more independent housing option. The program utilizes both single and double scattered site rental units located in the City of Schenectady and has the capacity to serve 40 individuals at any given time. The level of service provided by staff varies according to the needs of each individual. In addition to housing and ongoing support and encouragement the program offers restorative services and skill building training in the following areas:

• Symptom Management • Rehabilitation Counseling
• Daily Living Skills • Socialization
• Budgeting • Vocational Skill Development.
• Health Services • Substance Abuse Services
• Medication Management • Parenting Training
• Assertiveness and Self Advocacy    • Community Integration


Apartment Program staff are also available on an on-call basis to assist clients during times of crises. 


Program staff work collaboratively with other community service providers to ensure identified needs of all individuals served are addressed i.e. mental health and or substance abuse treatment, health care, public assistance, etc. An individualized service plan is developed with and for each resident upon their entry into the program and is used to guide service delivery and to help prepare residents for transition to a more independent living situation. 

The Certified Apartment Program staffing includes a Program Director, 2 Assistant Program Directors, and a team of Service Coordinators, and a Case Manager.

All referrals to our Certified Apartment Program must be forwarded to and reviewed by the Schenectady County SPOA Coordinator. Once forwarded to the program by the SPOA Coordinator, all referrals are processed within 72 hours. 

To be eligible for admission to the Certified Apartment Program, individuals must meet the following criteria:

• 18 years of age or older
• A primary diagnosis of a psychiatric illness.
• Not currently assessed as being dangerous to self or others or otherwise in need of hospitalization.
• Have a documented inability to live independently in the community.
• In adequate health so as not to require skilled nursing care.
• Voluntarily agree to comply with Mohawk Opportunities, Inc. Residency Agreement.
• Must demonstrate a willingness to assist in securing necessary funds to cover the cost of care and services.

 

Participation in the Certified Apartment Program is voluntary. 

No person shall be excluded from admission to the program based on race, religion, ethnicity, age, gender, sexual orientation or HIV status.

Supported Housing Program

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Mohawk Opportunities’ Supported Housing Program provides affordable housing and community based supports to individuals with a severe and persistent mental illness who have a continuing need for such services as move forward on their journey towards living independently in the community. The services offered by the program are less intense than those provided by the Certified Apartment Program. The services are intended to provide support and encouragement and reinforce the use of skills related to community living. The program utilizes scattered site rental units located in the City of Schenectady and has the capacity to serve 42 individuals at any given time. The level of service provided by staff varies according to the needs of each individual.

Five (5) of the Supported Housing Program slots are reserved for young adults ages 17 to 23 who have been diagnosed with a major mental illness. In addition to help in obtaining affordable housing and ongoing supports, these individuals are also offered more focused training in independent living skills – budgeting, household management, shopping, meal preparation etc.

Program staff work collaboratively with other community service providers to ensure identified needs of all individuals served are addressed i.e. mental health and or substance abuse treatment, health care, public assistance, etc. An individualized service plan is developed with and for each resident upon their entry into the program and is used to guide service delivery and to help prepare residents for transition to a more independent living situation.

The Supported Housing Program staffing includes a Program Director, an Assistant Program Directors, and a team of Housing Coordinators.

All referrals to our Supported Housing Program must be forwarded to and reviewed by the Schenectady County SPOA Coordinator. Once forwarded to the program by the SPOA Coordinator, all referrals are processed within 72 hours.

To be eligible for admission to the Supported Housing Program, individuals must meet the following criteria:

• 17 years of age or older
• A primary diagnosis of a psychiatric illness
• Not currently assessed as being dangerous to self or others or otherwise in need of hospitalization
• In adequate health so as not to require skilled nursing care
• Voluntarily agree to comply with Mohawk Opportunities, Inc. Residency Agreement
• Must demonstrate a willingness to assist in securing necessary funds to cover the cost of case and services

 

Participation in the Supported Housing Program is voluntary.

No person shall be excluded from admission to the program based on race, religion, ethnicity, age, sex, sexual orientation or HIV status.

Supported Housing – Continuum of Care Services

The Supported Housing Program also provides affordable housing and community based supports to individuals with a history of mental illness or who are HIV positive and are homeless. The services offered by this program component are aimed at helping these individuals obtain an apartment and develop the skills needed to maintain permanent housing in the community. The program utilizes single rental units located in the City of Schenectady and has the capacity to serve 28 individuals at any given time. Families are also able to be served. The level of service provided by staff varies according to the needs of each individual/family. 

Program staff work collaboratively with other community service providers to ensure identified needs of all individuals served are addressed i.e. mental health and or substance abuse treatment, health care, public assistance, etc. An individualized service plan is developed with and for each resident upon their entry into the program and is used to guide service delivery. 

Referrals to the Continuum of Care component of the Supported Housing Program can be made directly to the program by calling the Program Director. Once received, all referrals are processed within 72 hours. 

To be eligible for Continuum of Care services, individuals must meet the following criteria:

• 18 years of age or older
• A primary diagnosis of a psychiatric illness or HIV/AIDS
• Documentation of “homelessness” as defined by HUD.
• Not currently assessed as being dangerous to self or others or otherwise in need of hospitalization
• Voluntarily agree to comply with Mohawk Opportunities, Inc. Residency Agreement
• Must demonstrate a willingness to assist in securing necessary funds to cover the cost of case and services

Participation in the Continuum of Care component of the Supported Housing Program is voluntary. 

No person shall be excluded from admission to the program based on race, religion, ethnicity, age, sex, sexual orientation or HIV status.

Supported Housing – Rental Assistance Program

Mohawk Opportunities’ Supported Housing Program also provides affordable housing and community based supports to individuals with a history of mental illness or who are HIV positive and are homeless. The services offered by this program component are aimed at helping these individuals obtain an apartment and develop the skills needed to maintain permanent housing in the community. The program utilizes single rental units located in the City of Schenectady and has the capacity to serve 13 individuals at any given time. Families are also able to be served. The level of service provided by staff varies according to the needs of each individual/family. 

Program staff work collaboratively with other community service providers to ensure identified needs of all individuals served are addressed i.e. mental health and or substance abuse treatment, health care, public assistance, etc. An individualized service plan is developed with and for each resident upon their entry into the program and is used to guide service delivery. 

Referrals to the Continuum of Care component of the Supported Housing Program can be made directly to the program by calling the Program Director. Once received, all referrals are processed within 72 hours. 

To be eligible for Continuum of Care services, individuals must meet the following criteria:

• 18 years of age or older
• A primary diagnosis of a psychiatric illness or HIV/AIDS
• Documentation of “homelessness” as defined by HUD.
• Not currently assessed as being dangerous to self or others or otherwise in need of hospitalization
• Voluntarily agree to comply with Mohawk Opportunities, Inc. Residency Agreement
• Must demonstrate a willingness to assist in securing necessary funds to cover the cost of case and services

Participation in the Continuum of Care component of the Supported Housing Program is voluntary. 

No person shall be excluded from admission to the program based on race, religion, ethnicity, age, sex, sexual orientation or HIV status.

Transitional Case Management Program

Mohawk Opportunities Inc. Transitional Case Management Program is designed to provide 30 days of intensive support to adults over the age of 18 who are returning to community living following an inpatient psychiatric admission or incarceration.  The goal of these services is to assist people during vulnerable transitions and support their successful return to the community.

Forensic Transitional Case Management provides short term supports and quick access to needed psychiatric medication to individuals with a history of mental illness who have recently been released from jail, prison, or a psychiatric facility.  Through a grant mandated by Assisted Outpatient Treatment (AOT) Mental Hygiene Law and provided through the New York State Office of Mental Health, our Forensic Transitional Case Manager works closely with release/discharge coordinators from correctional facilities and hospitals to identify individuals who will be in need of mental health services upon their return to the community.  The Forensic Transitional Case Manager is then able to link these individuals to needed services in the community and provide them with a Medication Grant Card that will enable them to obtain needed medications while they await Medicaid eligibility determination or obtain third party health insurance.  Referrals are generated by prisons and the Schenectady County Jail.  The Forensic Transitional Case Manager also provides representative payee services to 25 individuals linked to Mohawk Opportunities.

Funded by the Delivery System Reform Incentive Payment (DSRIP) Program and developed in conjunction with Ellis Hospital’s Inpatient Psychiatric Services, the Intensive Transitional Case Manager works with individuals during and following a period of hospitalization providing them with the assistance needed to support their follow through with the discharge plan and overcome obstacles that often lead to reoccurring hospitalizations.  Referrals are facilitated by the Ellis Hospital Inpatient Psychiatric Social Work Staff and warm hand offs occur while the individual is still in the hospital.  The Intensive Transitional Case Manager has the capacity to transport clients home on the day of discharge.  Typically the Intensive Transitional Case Manager will also accompany the individual to the pharmacy for pick-up of medications and insure that the individual has access to food etc..  The Intensive Transitional Case Manager has the capacity to bring the individual to all 30 day follow up appointments, refer to other case management services, and coordinate care with community providers.

 

Participation in the Transitional Case Management Program is voluntary. 

No person shall be excluded from admission to the program based on race, religion, ethnicity, age, sex, sexual orientation or HIV status.

Care Management Program

Mohawk Opportunities’ Care Management Program provides assistance to individuals living with chronic medical and behavioral health conditions in an effort to help them improve their general functioning, achieve positive health outcomes and reach personal goals.  The program is designed to link individuals with needed services – Primary Care, Specialty Care, Mental Health Treatment, Alcohol and other Drug Treatment, transportation, housing, social service agencies and other community resources – and foster their ongoing work with providers.  Once linked, Care Management continues to serve individuals by coordinating care, collaborating with other providers, and providing support to the individual and identified family members with the goal of improved health and a reduction in the reliance on emergency rooms and inpatient care.  Care Management is a community based service.

The Care Management Program also assists individuals enrolled in the Health and Recovery Plan (HARP) to access Home and Community Based Services.

Mohawk’s Care Management services are linked with an individual’s enrollment in Care Central, a NYS Certified Heath Home operated by the Visiting Nurse Service of Schenectady and Saratoga Counties.  In order to qualify for services, an individual must be Medicaid eligible and carry a diagnosis of HIV or Serious Mental Illness, or have two or more chronic health conditions.  Chronic health conditions may include asthma, obesity, diabetes, and heart disease among others.  While we serve all populations, our specialty is working with adults with Serious Mental Illness.

The Care Management Program consists of a Program Director with Master’s level clinical experience, a Senior Health Home Care Manager serving the HARP population, and multiple generalist Care Managers.

Referrals come to the Care Management Program via many different sources.  A Care Central referral form must be completed and faxed either to Care Central or directly to the Care Management Program Director.

 

Participation in the Care Management Program is voluntary. 

No person shall be excluded from admission to the program based on race, religion, ethnicity, age, sex, sexual orientation or HIV status.