Care Coordination Organizations (CCOs) assist those who qualify for OPWDD services in the coordination of health care, behavioral health, and disability services.

Health Home Care Management services given by Care Coordination Organizations (CCOs) assist New Yorkers who qualify for OPWDD services in the coordination of health care, behavioral health, and developmental disability services for themselves and their families. Health Home Care Management is comprised of six core functions:

  • Comprehensive care management
  • Care coordination and health promotion
  • Comprehensive transitional care from inpatient to other settings, which includes appropriate follow-up
  • Individual and family support
  • Referral to community and social services
  • The use of health information technology (HIT) to link services.

What is Care Management?

Care management is the service that helps you and your family get the services and supports you need. Care management is provided by Care Managers who work for Care Coordination Organizations (CCOs), which are organizations that were formed by developmental disability service providers and are staffed by Care Managers with training and experience in the field of developmental disabilities. Your Care Manager will coordinate a variety of healthcare, wellness and developmental disabilities services to meet your needs.

You will need to choose the CCO that you want from the list of CCOs that provide services in your region. Your CCO will help you with the OPWDD eligibility determination process, the Level of Care Eligibility Determination process and the process of enrolling in Medicaid. To enroll in a CCO and receive the services of a Care Manager, you will need to successfully complete the CCO application and processes. Once you have enrolled in your CCO, you will choose the care management plan that best meets your needs.

The two care management choices are:

Health Home Care Management – the more robust, comprehensive care management service which provides:

  • Coordination of the developmental disability services that you and your family need or are currently receiving,
  • Comprehensive coordination of other health and behavioral health care services you need or receive.

Basic HCBS Plan – focuses on planning related only to HCBS waiver services and does not coordinate any other health or behavioral health services. With this service, your Care Manager will work with you to:

  • Develop, review and update your Life Plan (service plan),
  • Ensure that your annual, needed Level of Care Eligibility Determination (LCED) is completed.

A specialized team, made up of a Care Manager working together with other professionals, will work with you and your family to develop your individualized Life Plan (plan of services). This team will make sure that your services are provided the way they are supposed to be and make changes when you need them. Care Managers promote and support Informed Choice – a choice that a person makes based on a good understanding of the options available to him or her, and how each option may affect his or her life.

Your Care Manager provides information to you so you can make informed choices about your life and services. You may be supported to make an informed choice on your own, or may have assistance from family members, friends or other people important to you.

The Circle of Support

Developing Individualized Services Using Person Centered Planning You, the person receiving services, are at the “center” of your Circle of Support. Your Circle of Support includes the people you choose, and may include family members, friends, or other people important to you. Your circle can be as small as you and your Care Manager, or can be larger. Your circle meets regularly to work with you to:

  • Develop a plan for the supports and services you want
  • To evaluate the success of your current plan
  • To make changes to your plan when necessary.

Your Care Manager focuses planning on your needs and interests, drawing input from you and your Circle of Support. Everyone works cooperatively to develop a personalized plan of services for you.

Your Life Plan

Your Care Manager will work with you and your family/Circle of Support to develop your Life Plan, an individualized service plan designed just for you. Your Life Plan is a roadmap to your personal goals and describes the supports and services that will help get you there. Your Care Manager:

  • Develops your Life Plan using a person-centered approach, working with you, and other people you and your family think should be involved
  • Helps you make informed choices and develop a personal network of activities, supports, services, and community resources based on your needs and desires
  • Documents the supports, services and community resources needed and chosen by you, and details how you will access them in your Life Plan
  • Helps you identify the additional care coordination activities and interventions that you want and need to meet your individualized goals and valued outcomes as described in your Life Plan

To implement your Life Plan, your Care Manager:

  • Shares his or her knowledge of the community and researches available resources to help you make informed choices about how to achieve your valued outcomes
  • Makes referrals and facilitates visits and interviews with family members, service providers, housing options, and other alternatives so that you can make informed choices
  • Coordinates access to and delivery of supports and services identified in your Life Plan, including both natural supports and funded services.

Care Coordination Organizations (CCOs)

Care Coordination Organizations (CCOs) are new entities formed by existing providers of developmental disability services to coordinate all of the services a person receives for their developmental disability as well as the coordination of health, wellness, and mental health services.

CCOs use an electronic health record system that connects all of the service providers participating in your care and makes your health information and Life Plan available to you and your care team at all times. All CCOs are required to adhere to stringent security procedures in order to secure your Personal Health Information.

The Care Managers work in collaboration with the front door facilitators at the OPWDD to provide support to the clients they serve. It is their responsibility to assist in the organization and coordination of the activities of the individuals, including making referrals for medical assessments, psychological and psychosocial evaluations, recreational and educational services, counseling services, and other emergency services as required by the individuals themselves. In addition, the Care Coordinators help the persons in getting residential housing and day rehabilitation programs, among other services. First and foremost, the Care Managers do follow-ups to verify that all referrals are carried out in accordance with protocol.