Our Services

NHTD and TBI Waiver Service Coordination in New York

We provide Service Coordination for individuals enrolled in the Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) Waiver Programs in New York. Our role is to help participants live safely in their preferred community setting by ensuring they have the services and supports needed to remain at home or transition out of a nursing facility.

We work closely with participants, families, and providers to ensure care is appropriate, well coordinated, and responsive to changing needs.

What Is Service Coordination?

Service Coordination is a core part of the NHTD and TBI Waiver Programs. A Service Coordinator serves as the primary point of contact and guide throughout a participant's time in the waiver.

Service Coordination includes:

Identifying needs and goals in collaboration with the participant and family
Developing and maintaining an individualized service plan
Coordinating waiver and community-based services
Supporting ongoing Medicaid and waiver eligibility
Monitoring services and addressing concerns as they arise
Advocating to ensure services align with participant needs and preferences

How We Support Participants and Families

Our Service Coordination services include:

Guidance through the waiver application and enrollment process
Assistance with Medicaid eligibility, renewals, and required documentation
Development and ongoing monitoring of individualized care plans
Coordination of waiver and community-based services
Ongoing communication with families, providers, and care teams
Support during transitions, hospitalizations, and changes in care needs
Advocacy to help prevent gaps in services and unnecessary institutional placement

Supporting Community Living

A primary goal of the NHTD and TBI Waiver Programs is to support individuals in living safely in the community. We assist participants by coordinating services and supports that promote independence, stability, and safety.

This includes helping individuals:

Transition home from a nursing facility
Maintain services that allow them to remain safely in the community
Navigate changes in care needs without disruption to services

Additional Services We Help Participants Access

While we do not provide direct or hands-on services, we help participants identify, apply for, and coordinate waiver and community-based services based on individual needs and eligibility.

These may include:

Home Care Services

Personal Bracing and Individualized Supports (PBIS)

Consumer-Directed Personal Assistance (CDPAP)

Community Integration Counseling (CIC)

Environmental Modifications (E-Mod)

Assistive Technology and Adaptive Equipment

Structured Day Program (SDP)

Community Transitional Services (CTS)

Who We Work With

We collaborate closely with:

Participants and their families or caregivers
Home care agencies and waiver service providers
Hospitals, rehabilitation facilities, and discharge planners
Therapists and other community-based providers