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Home and Community Based Services

Through participation in Health and Recovery Plans (HARPs), Medicaid-insured individuals have access to an array of Home and Community Based Services (HCBS) that promote the integration of physical and behavioral health recovery. Designated by New York State, the services are recovery-oriented in that they endorse the concept that individuals can recover from mental illness and substance use disorders. In addition, services are person-centered, culturally competent, trauma informed and peer informed. Circare’s HCBS program incorporates these core principles and values as well as our vast experience in providing employment, peer-based, clinical and care management services.

The following nine services are offered at Circare as part of HCBS:

Eligibility Criteria

  • Medicaid insured
  • Enrolled in a Health and Recovery Plan (HARP) through a Managed Care Organization
  • 21 years of age and older
  • Persistent mental health diagnosis or substance use disorder.

Referral Process/Questions

HARP participants interested in HCBS must complete an assessment administered by a designated Health Home. For more information regarding the assessment process and HCBS, please click one of the services above for Circare staff contact information.


Psychosocial Rehabilitation (PSR)

Circare Psychosocial Rehabilitation services are for eligible adults who want to experience fuller lives, fewer barriers, and greater integration with family and community. This service is designed for individuals who may have had strong skills in the past but at present skills need to be restored. Services are based on the participant’s Plan of Care and may include but not be limited to the following components:

  • Rehabilitation counseling
  • Recovery-oriented activities
  • Activities to improve social and interpersonal skills
  • Enhancing self-awareness, self-advocacy, assertiveness, negotiation, and problem-solving skills
  • Enhancing personal care and hygiene
  • Increasing mobility and use of public transportation
  • Domestic skills development—shopping, meal planning/preparation, housekeeping, budgeting, and financial fitness
  • Shared decision-making and problem solving
  • Coaching for relapse prevention skills
  • Increasing awareness of resources in the community
  • Developing support networks
  • Family reunification, if applicable
  • Exploration of talents and interests
  • Developing and implementing wellness and crisis plans
  • Ongoing assessments to chart progress toward individual goals
  • Creating a “tool box” of strategies to help deal with intense emotions, symptoms, and triggers
  • Services may be provided in an individual or group format

Questions

Jason Erwin
Director of Peer Services
315-472-7363 ext. 248


Community Psychiatric Support and Treatment (CPST)

Circare Community Psychiatric Support and Treatment (CPST) services are for eligible adults who have had difficulty using office-based mental health treatment, and may benefit from services delivered at home or in a community setting. The goal of the service is to assist participants in achieving stability and improved functioning in daily living, personal recovery, family/relationships, and community integration. The service is intended to help participants eventually transition to more traditional office-based treatment. Services are based on the participant’s Plan of Care and may include but not be limited to the following components.

  • Provide clinic services in a home/community setting-- therapeutic counseling, interventions, behavioral analysis and behavior management
  • Involve family of choice/collaterals as supports in treatment (if desired)
  • Assess needs and strengths and utilize a strengths- based approach to treatment
  • Help participants minimize behaviors and stressors that interfere with functioning
  • Help participants identify and effectively respond to precursors, triggers, or risk factors that may interfere with successful community living
  • Help participants develop skills in the areas of independent living, social/interpersonal, self-care, medication/health management, money management, use community supports, and other
  • Provide rehabilitation support for participants seeking employment, housing, and education
  • Assist participants in identifying natural supports to enhance treatment and crisis management
  • Develop a crisis management plan and supports to maintain stability and functioning
  • Utilize evidence-based and best practices in psychotherapeutic approach to treatment

Questions

Sara Paolini
Director, Circare Outpatient Behavioral Health Clinic
315-472-7363 ext. 413


Habilitation

Circare Habilitation services are for eligible adults who want to develop or improve skills required for community living. These skills enhance independence, safety, and community integration. Habilitation services are designed for individuals with mental health and/or substance use disorders who are in the process of recovery. Services are based on the participant’s Plan of Care and may focus on, but not be limited to, skill development in the following areas:

  • Communication
  • Self-care and advocacy
  • Social and relationship skills
  • Mobility and use of public transportation
  • Personal adjustment and wellness
  • Domestic skills development—shopping, meal planning/preparation, housekeeping, budgeting and financial fitness
  • Finding housing and interacting with landlords and roommates
  • Shared decision-making and problem-solving skills
  • Use of community resources
  • Family reunification, if applicable
  • Developing and implementing wellness and crisis plans
  • Creating a “tool box” of strategies to help deal intense emotions, symptoms, and triggers
  • Services are provided in an individual format only (no group format)

Questions

Jason Erwin
Director of Peer Services
315-472-7363 ext. 248


Family Support and Training

Circare Family Support and Training services are for eligible adults who want to engage family members as resources in treatment and recovery. “Family” is defined broadly and may include relatives and non-relatives who live with or voluntarily provide care for an individual. The contact person named below can help answer questions about the definition of “family” for purposes of this service.

Services are based on the participant’s Plan of Care and may include, but not be limited to, family support and training in the following areas:

  • Learning about medical and recovery models, diagnoses, treatments, and medications
  • Maintaining a safe, calm, and supportive environment
  • Using hope-based and not fear-based language
  • Recognizing and addressing trauma (focus on what happened not what went wrong)
  • Sharing in decision-making and risks
  • Using paid supports effectively
  • Setting and moving toward goals, hopes, and dreams
  • Empowering rather than enabling
  • Providing mediation and conflict resolution within family
  • Offering peer-assisted support in setting up family/friend support groups
  • Providing tools to help the family and participant with problem-solving, coping strategies, symptom/behavior management skills, and relapse prevention
  • Reinforcing social skills and activities of daily living (ADL’s) for independence and community involvement
  • Building on family’s strengths and strengthening family relationships
  • Consulting with family and caregivers on interventions
  • Explaining nuts and bolts to family—service plans, crisis/safety plans, waiver process, etc.
  • Presenting trainings and workshops on topics that may be relevant such as
    trauma, validation, communication, emotional regulation, boundaries, violence prevention, suicide prevention and other as needed
  • Providing information on community resources, government agencies, and benefits/entitlements
  • Developing and implementing wellness and crisis plans
  • Creating a “tool box” of strategies to help deal with intense emotions, symptoms, and triggers
  • Services may be provided in a group or individual format

Questions

Jason Erwin
Director of Peer Services
315-472-7363 ext. 248


Education Support Services

Circare Education Support Services are for eligible adults with an assessed need for educational support services, and a clearly expressed interest in gaining employment with skills acquired. Services are based on employment or skill development goals documented in the participant’s Plan of Care. They may include but not be limited to:

  • Assistance applying for college programs/courses, vocational training, and apprenticeship programs
  • Linkages to tutoring to prepare for a Test Assessing Secondary Completion (TASC) diploma
  • Motivational interviewing to help participant identify/activate education and employment goals
  • Serving as a resource on educational opportunities, financial aid, and other educational resources and supports
  • Linkages to supportive services for learning and cognitive disabilities
  • Assistance with admissions, financial aid, registrations, transitions, withdrawals and other changes in status
  • Orientation to school setting, system, and relevant student service offices
  • Providing remediation for cognitive skills involved in organizing, planning, attention, memory
  • Ongoing assessment of needs, strengths, and requirements for services and accommodations
  • Educational skill building in relation to studying, taking notes, managing time and stress
  • Social skill building and self-advocacy training for independence
  • Provide advocacy support for appropriate classroom accommodations relevant to disability
  • Assistance may continue after participant has successfully enrolled in educational program if follow-along support is needed
  • Services are provided in an individual format only (no group format)

Questions

Brian Cappon
Vocational Services Supervisor
315-472-7363 ext. 214

Tracy Bassett
Vocational Specialist
315-472-7363 ext. 212


Empowerment Services – Peer Supports

Circare Empowerment Services are entirely peer-delivered. Services focus on rehabilitation and recovery. Services are designed to help participants develop coping skills, manage behavioral symptoms, and utilize natural supports and resources. A trauma-informed, non-clinical approach is used to promote lasting recovery from a mental health or substance use disorder. Skills and strategies for recovery are learned through shared personal experience.

Services are based on the goals and objectives documented in the participant’s Plan of Care. They may include but not be limited to:

  • Assistance securing food, shelter, and permanent residency
  • Providing advisement on benefits and entitlements
  • Linking participants to systems of care and assisting with any navigational barriers
  • Helping participants plan and advocate for self-directed care
  • Providing companionship and modeling a lifestyle of recovery
  • Promoting awareness of resources for recovery and barrier removal
  • Visiting and assisting with transitions from hospitals, treatment centers, etc.
  • Assisting with selection and implementation of tools for recovery and preventing relapse
  • Encouraging participants to pursue passions which bring quality and meaning to life
  • Helping participants connect with natural supports and self-help groups
  • Educating and coaching participant and family on recovery
  • Encouraging goals that promote community connection, wellness, spirituality, employment, self-help, and safety
  • Providing skill building required for independent living
  • Providing transitional supports for those moving from jail or institution to home and community
  • Offering a supportive presence at times of pre-crisis and crisis
  • Developing and implementing wellness and crisis plans
  • Creating a “tool box” to help deal with intense emotions, symptoms, and triggers
  • Services are provided in an individual format only (no group format)

Questions

Jason Erwin
Director of Peer Services
(315) 472-7363 ext. 248


Pre-Vocational Services

Circare Pre-Vocational Services are for eligible adults who require supports to prepare for a new job (paid or unpaid) or to maintain current employment. Services are short-term and focus on developing soft skills and employment strengths that are more general in nature and not job/task specific. Services are based on the goals and objectives documented in the participant’s Plan of Care. They may include but not be limited to the following activities:

  • Identify key components of workplace culture
  • Recognize and overcome obstacles to employment
  • Offer guidance on appropriate dress and personal hygiene
  • Discuss the importance of punctuality and attendance
  • Develop problem solving skills
  • Review workplace compliance and safety
  • Develop individualized workplace coping skills
  • Create a vocational goal with at least 3 objectives
  • Create draft of resume
  • Assess strength and barriers
  • Prepare for difficult interview questions regarding gaps in employment, criminal history, disability disclosure, need for accommodations, lack of experience and other
  • Reassess goals and objectives
  • Explore job descriptions/openings to identify employment options and qualifications required
  • Use Career Zone and other electronic/web resources for employment exploration
  • Provide guidance on benefit planning
  • Assess difficulties, and discuss “reasonable accommodation” framework (focus on functions not symptoms)
  • Assess availability of employer incentives
  • Offer peer service options to improve prospect of success
  • Assess need for mental and physical health interventions that may support employment goals
  • Discuss possible move to next service level which is Intensive Supportive Employment (ISE)

Questions

Brian Cappon
Vocational Services Supervisor
315-472-7363 ext. 214

Tracy Bassett
Vocational Specialist
315-472-7363 ext. 212


Intensive Supported Employment (ISE)

Circare Intensive Supported Employment (ISE) services are for eligible adults who require intensive supports to obtain paid employment or to maintain current paid employment in the competitive workforce. Employment compensation must be at minimum wage or higher. Services and supports are delivered consistent with the evidence-based model of Individual Placement Support (IPS). Services are based on the goals and objectives documented in the participant’s Plan of Care. They may include but not be limited to the following activities:

  • Develop application template
  • Select resume type—chronological, skills-based, functional, hybrid
  • Create professional resumes and cover letters
  • Compile list of references
  • Participate in development of online job search strategies
  • Create email address
  • Discuss use of social media—Linkedin, Facebook, Twitter, etc.
  • Distinguish appropriate phone messaging, texting, and other communication with potential employer
  • Organize a job search folder containing key job search information
  • Develop list of online job search strategies
  • Introduce One Stop Career Center and other electronic resources
  • Provide training on career development software and web-based tools
  • Investigate 55b/c program opportunities for government employment for persons with disabilities
  • Reassess initial vocational goal and add goals and objectives if needed
  • Develop an Individual Plan for Employment
  • Offer peer service options to improve prospect of success
  • Assess need for mental and physical health interventions that may support employment goals

Questions

Brian Cappon
Vocational Services Supervisor
315-472-7363 ext. 214

Tracy Bassett
Vocational Specialist
315-472-7363 ext. 212


Ongoing Supported Employment

Circare Ongoing Supported Employment services are for eligible adults who are already competitively employed in an integrated community setting with paid compensation at or above minimum wage. The support provided is considered to be follow-along support, and is intended to assist the participant in maintaining current employment in the competitive workforce. Services are consistent with the goals and objectives documented in the participant’s Plan of Care. Services may include but not be limited to the following activities:

  • Facilitate adjustment to workplace culture
  • Develop a transportation plan if needed
  • Develop a personal schedule to accommodate work and personal needs
  • Develop a plan to balance multiple roles/responsibilities—daycare, family, maintaining health, participation in support groups, quality of life issues, and other
  • Provide Work Incentive Benefit Planning
  • Document key milestones, benchmarks, and earnings associated with intervention points
  • Address continued healthcare planning and healthcare literacy
  • Assess insurance options—private, Medicaid, Medicaid Buy In For Working People with Disabilities, 1619b working on Medicaid with SSI
  • Refer/facilitate transition from Medicaid to other forms of health insurance
  • Offer peer service options to improve prospect of success
  • Assess need for mental and physical health interventions that may support employment goals

Questions

Brian Cappon
Vocational Services Supervisor
315-472-7363 ext. 214

Tracy Bassett
Vocational Specialist
315-472-7363 ext. 212