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Patients with serious mental illness (SMI) can benefit from supportive services to support treatment adherence and benefits enrollment, including housing services.Â
Some programs may have waitlists. Programs that generally do not have waitlists include Sheltered Partnered Assertive Community Treatment (Shelter Partnered ACT), Health Homes/Care Coordination, and Safe Options Support (SOS).
Mobile health program for patients with SMI in shelter or safe haven
Program: Assertive Community Treatment (ACT)
Description: Treatment for people with a serious mental illness who have high service needs that are not being met in traditional settings. People with serious mental illness who are otherwise unable to connect to community treatment can receive clinical support from an interdisciplinary team.
Includes:Â
- Shelter Partnered ACT (SPACT) for people who are residents of designated mental health shelters
- Forensic ACT (FACT) for people with current/past criminal justice involvement
Referral process: Online application via NYC DOHMH Single Point of Access (SPOA). A psychosocial evaluation within the last 6 months, or an observational psychiatric evaluation, is required.
Mobile health program for patients with SMI in shelter, safe haven or who are/subway street homeless
(for patients with recent and frequent contact with mental health and criminal justice systems)
Program: Intensive Mobile Treatment (IMT)
Description: For people with serious behavioral health concerns, very complex life situations, transient living situations and/or criminal justice involvement
Referral process: Online application via NYC DOHMH Single Point of Access (SPOA). A psychosocial evaluation within the last 6 months, or an observational psychiatric evaluation, is required.
For people with SMI on Medicaid waitlisted for ACT or IMT
Program: Health Homes Plus (HH+)
Description: Care management services for high-need Medicaid-eligible people with serious mental illness
Referral process: Enroll via OMH Specialty Mental Health Care Management Agencies.
For people with SMI not eligible for Medicaid waitlisted for ACT or IMT
Program: Non-Medicaid Care Coordination
Description: Care management services for high-need people with serious mental illness not eligible for Medicaid
Referral process: Online application via NYC DOHMH Single Point of Access (SPOA). A psychosocial evaluation within the last 6 months, or an observational psychiatric evaluation, is required.
Outreach and care coordination for people experiencing chronic street homelessness
Program: Safe Options Support (SOS) - care coordination and linkage to mental health treatment
Description: For patients experiencing street/subway homelessness. Services include: outreach and canvassing; assistance enrolling in housing/employment assistance, benefits, legal services; linkage to medical care, including substance use and behavioral health treatment
Referral process: Email referral form to SOSInfo@cbcare.org,or call 1-866-SOS-4NYC to discuss referral
Assistive Outpatient Treatment (AOT) is court-ordered treatment for people who have difficulty engaging in treatment and poses risk to self/others. Learn more
On-site and mobile homeless primary care
Program: Safety Net Clinics: On-site primary care and specialty care
Description: Integrated primary care, addiction treatment and behavioral health care, care coordination, and linkage to specialty care for people with multiple chronic health conditions who are experiencing homelessness
Referral process: Contact information for patient referrals
Program: Street Health Outreach and Wellness (SHOW) vans: Mobile clinic for health screenings and referrals
Description: Medical care, behavioral health resources, harm reduction, and material goods to people who are unsheltered or living on the street
Referral process: Refer through Safetynet Clinic referral contacts
Care coordination for chronic health conditions
Program: Medicaid Health Homes
Description: People enrolled in a Health Home are assigned a care manager who will develop a care plan and connect enrollees to health care providers, behavioral health providers, medications, housing and social services. Eligible patients must have or more chronic conditions or one single qualifying chronic condition (HIV/AIDS, serious mental illness, sickle cell disease). Learn more
Referral process: Contact a Health Home in the patient's borough of residence. To determine patient's borough of residence, contact the DHS Institutional Referral Program. Some Health Homes can accommodate multiple boroughs of residence.
Connect clients to a community health worker program at their facility.
Home care agencies can be found on the NYS Department of Health website.