Our Services
NHTD and TBI Waiver Service Coordination in New York
Guiding You Every Step of the Way
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 Coordination agency serves as the primary point of contact and navigator throughout the application process and maintains active, ongoing involvement throughout a participant's enrollment in the waiver services.
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:
Waiver Enrollment Support
Guidance through the waiver application and enrollment process, including what to expect and which documents are required.
Medicaid Renewals and Documentation
Assistance with Medicaid eligibility, renewals, and required paperwork so coverage and services remain active.
Individualized Service Planning
Development and ongoing monitoring of individualized care plans to ensure services match current needs.
Service Coordination and Follow-Through
Coordination of waiver and community-based services, with ongoing communication among families, providers, and care teams.
Support During Changes
Assistance during transitions, hospitalizations, and changes in care needs to reduce disruption in services.
Advocacy
Advocacy to help prevent service gaps 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
- Supports community living through diversion from nursing home placement
- Manages evolving care needs without disruption to services already in place
Services We Help Participants Access
While we do not provide these services directly, we help participants identify, apply for, and coordinate other waiver and community-based services based on individual needs and eligibility.
These may include:
In-Home Support
Consumer-Directed Personal Assistance Program (CDPAP)
Home and Community Support Services (HCSS)
Community & Counseling Supports
Community Integration Counseling (CIC)
Structured Day Program (SDP)
Personal Bracing and Individualized Supports (PBIS)
Home & Safety Supports
Environmental Modifications (E-Mod)
Assistive Technology (AT) and Adaptive Equipment
Transition Support
Community Transitional Services (CTS)
Waiver Housing Subsidies
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
Ready to Learn More?
Contact us to discuss how our Service Coordination can support you or your loved ones.
Contact Us