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Service Delivery Innovation Profile

Care Coordinators Support Individuals With Severe Mental Illness, Leading to Improved Quality of Life and Lower Costs

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The seven-county New York Care Coordination Program (formerly Western New York Care Coordination Program) offers person-centered, recovery-focused care coordination for individuals with severe mental illness (e.g., schizophrenia, bipolar disorder, clinical depression) who have had at least one psychiatric hospitalization. Care coordinators perform a comprehensive assessment of client needs and then help the client to define recovery goals, develop a care plan to meet those goals, and access community-based programs and services related to behavioral and physical health care, housing, nutrition, transportation, and social support. The program has improved quality of life and coping skills and reduced emergency department visits, inpatient days, and costs; in addition, those served by the program have become increasingly satisfied with it over time.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons and/or trend data on a variety of self-reported quality-of-life and coping skills indicators, ED visits, inpatient days, and measures of enrollee satisfaction, along with comparisons of mental health services costs in participating and similar nonparticipating counties, and comparisons of growth in Medicaid claim costs in two participating counties to statewide averages.
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Developing Organizations

Western New York Care Coordination Program
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Date First Implemented

Julybegin pp

Patient Population

Vulnerable Populations > Mentally illend pp

Problem Addressed

Individuals with serious mental illnesses often fare poorly after being discharged from psychiatric institutions, as evidenced by repeated hospital admissions. Such readmissions often occur as a result of poor access to community-based services, as newly discharged individuals may not be successful on their own in accessing and/or coordinating medical care and support services that help in achieving recovery.
  • Frequent readmissions: Many patients discharged from psychiatric hospitals require additional inpatient care, with readmission rates of 10 percent within 1 month of discharge to as high as 47 percent within 1 year.1,2
  • Driven in part by poor access to community-based services: Programs that provide support to recently released psychiatric inpatients (e.g., those related to housing, transportation, and nutrition) can help ensure successful reentry into the community. However, the vast majority of individuals learning to live with mental illness lack access to such support, which often leads to readmission to a psychiatric facility.3 In western New York State, mental health service providers became concerned about the poor recovery of those patients with serious mental illnesses who had a history of psychiatric hospitalization, particularly those with co-occurring medical illnesses. Although such patients had access to county-sponsored case management, these services did not sufficiently emphasize coordination of support services across systems and focused on alleviating symptoms rather than promoting recovery.

What They Did

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Description of the Innovative Activity

The New York Care Coordination Program offers a person-centered approach to care coordination for individuals with severe mental illness who have had at least one psychiatric hospitalization. The program links clients with care coordinators who perform a comprehensive needs assessment, and then help the client define recovery goals, develop a coordinated care plan to meet those goals, and access programs and services related to behavioral and physical health care, housing, nutrition, transportation, and social support. Care coordinators monitor client progress regularly and intervene promptly when needed. Key elements of the program include the following:
  • Referral and application process: The program serves individuals with severe mental illness, such as schizophrenia, bipolar disorder, and clinical depression. Psychiatrists, social workers, psychiatric hospital discharge planners, and community agencies can refer clients to the program; clients may also self-refer. The program serves approximately 2,800 individuals at any given time. A client completes an application for the program, which is then reviewed by one or two designated employees in each county. These gatekeepers use specific criteria to determine if an individual qualifies for either "intensive case management" or "supportive case management," as outlined below:
    • Intensive case management: Individuals who have complex behavioral and physical health needs can receive intensive case management, with four or more meetings per month with the care coordinator.
    • Supportive case management: Individuals with less complex needs meet with the care coordinator at least twice per month.
  • Comprehensive assessment of needs: Those who qualify for program services are assigned a care coordinator. The coordinator contacts the individual by phone or in person to set up an initial meeting, which typically takes place at the offices of the care coordination provider agency, in the individual's home, or in a community location, such as a coffee shop or restaurant. During this session, the coordinator works on engagement and frequently begins the assessment process, starting with a Quality of Life Self-Assessment which is completed by the enrollee. The coordinator conducts a comprehensive assessment of needs using an internally developed assessment tool. This process frequently involves use of motivational interviewing to identify life goals, steps to reach these goals, and barriers.
  • Customized care plan: The client and care coordinator create a customized care plan (known as an Individual Service Plan) based on the client's personal profile (e.g., values, strengths, family support, and barriers to recovery). This plan lays out goals and objectives, along with the supports and services that the client will access to meet them. The plan also covers crisis prevention, listing people/places/things to avoid, early warning signs, strategies for averting crisis, who to contact if a crisis occurs, and specific medications to use in the event of crisis. The plan is created within a month of enrollment and updated at least every 6 months.
  • Connection to community services: The care coordinator works with the client to facilitate access to needed services, including primary and specialty care (e.g., referring the client to a community mental health center or a primary care provider, making an appointment, and facilitating a first visit), housing (e.g., working with the client's landlord), prescription drugs (e.g., enrolling the client in discount programs), nutrition services (e.g., enrolling the client in government-sponsored programs), and transportation. The coordinator also communicates with friends and family members to ensure their ongoing support, discusses client needs with the client's employer (or helps in securing employment if necessary), and helps the client pursue educational support (e.g., tuition reimbursement).
  • Ongoing monitoring and as-needed intervention: At enrollment and no less frequently than semiannually thereafter, care coordinators monitor client progress versus the care plan by asking the enrollee to complete a new Quality of Life Self-Assessment and themselves completing a Care Coordinator's Assessment of Functioning form. Both documents rate 15 different areas of functioning on a scale of 0 (poor), 1 (fair), 2 (good), or 3 (excellent); areas include housing, finances, work or work readiness, level of education, transportation, social life with friends/family, community involvement, leisure pursuits, physical health, level of independence, activities of daily living, self-esteem/self-confidence, effect of alcohol/drugs, mental health symptoms, and overall functioning. A discussion of these ratings helps both the enrollee and the care coordinator to understand whether and how to adjust the plan, with a poor rating indicating the need for immediate intervention and a fair or good rating indicating the need for continued monitoring and potential intervention.

Context of the Innovation

The New York Care Coordination Program is a seven-county consortium that serves approximately 2,800 individuals with severe mental illness; the program strives to allow clients to meet life goals, achieve recovery, and live successfully in the community. The impetus for the program began in the late 1990s when New York State passed legislation to promote the development of managed care plans for individuals with serious mental illness. In response, a group of six counties in the western part of New York (Erie, Monroe, Onondaga, Chautauqua, Wyoming, and Genesee) agreed to collaborate. Although the legislation expired in 2000 due to provider concerns about inadequate funding for services, the six counties continue to work together. In 2010, Westchester County became the seventh county to join the program.

Did It Work?

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The program has improved quality of life and coping skills and reduced emergency department (ED) visits, inpatient days, and mental health and Medicaid claim costs; those served by the program have become increasingly satisfied with it over time.
  • Higher quality of life: A 2009 analysis that compared initial scores by enrollee with the most recent scores for those enrollees on a variety of quality-of-life indicators (measured at least 6 months apart) found significant improvements in scores, including increases in those reporting gainful activity (up by 31 percent), competitive employment (51 percent), and improved living situations (13 percent). In addition, fewer enrollees reported being arrested (instances of which fell by 25 percent), causing physical harm to others (53 percent) or themselves (54 percent), and facing worse living conditions (12 percent).
  • Better coping skills: Surveys using a scale of 0 to 5 (with higher numbers indicating better skills) found that enrollees improved a variety of coping skills, including being able to deal more effectively with daily problems (increase from 2.9 to 4.6) and crisis (3 to 3.9), doing better in school or work (2.7 to 3.8), getting along better with family (2.9 to 3.9), and having less bothersome symptoms (2.9 to 3.9).
  • Fewer ED visits and inpatient days: A 2009 analysis that tracked indicators over at least a 6-month period found that ED visits declined by 46 percent, while inpatient days (in either a psychiatric or general hospital) fell by 53 percent.
  • Lower mental health and Medicaid claim costs: A 2008 study compared data for enrollees in the participating counties with data for a comparable group of individuals in six comparable, nonparticipating counties in New York State. The study found that costs for inpatient mental health service in the six participating counties were 92 percent lower than in the six comparable, nonparticipating counties; participating counties also experienced lower outpatient (42 percent) and community support service (13 percent) costs. Between 2003 and 2009, Medicaid claim costs among participating individuals increased by 8 to 13 percent in two participating counties (Erie and Monroe, respectively), well below the 20-percent average increase among all disabled individuals in New York State, other than New York City.
  • Increasing satisfaction with program over time: Satisfaction among those served by the program increased between 2003 and 2009, with enrollees reporting higher satisfaction with the following: the care coordinator's belief in their ability to grow, change, and recover (which rose from 3.2 to 4.5 on a 0 to 5 scale); the care coordinator's acknowledgment of their dreams, interests, preferences, and strengths (3.1 to 4.3); their ability to choose and reject services (3.2 to 4.1); and the availability of self-help and peer support groups (3.1 to 4.1).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons and/or trend data on a variety of self-reported quality-of-life and coping skills indicators, ED visits, inpatient days, and measures of enrollee satisfaction, along with comparisons of mental health services costs in participating and similar nonparticipating counties, and comparisons of growth in Medicaid claim costs in two participating counties to statewide averages.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Securing funding: The group worked with the State Office of Mental Health, which agreed to join with the counties to pursue the goal of improving outcomes for individuals with serious mental illness, including funding support. Each county also committed funding for both the project level costs and the county level implementation costs.
  • Forming steering committee: The group formed a multistakeholder, multicounty steering committee, now including the seven county directors, four peer/family member representatives, and four providers.
  • Defining target population: The steering committee defined the target population as those individuals eligible for the New York State Targeted Case Management Program, a Medicaid-billable case management service (and in some instances the Assertive Community Treatment program). Eligible individuals have serious and persistent mental illness and frequently are in the top 10 percent of Medicaid costs for all physical, behavioral, and pharmacy services.
  • Designing program: The steering committee adapted the existing New York State case management structure to provide care coordination (rather than case management) within existing regulations and funding. The committee also created new forms to facilitate individualized planning and consumer choice.
  • Contracting for project management: The program contracted with Coordinated Care Services Incorporated, a not-for-profit company located in Rochester, NY, to provide project management services. Coordinated Care Services Incorporated is a management services firm with more than 25 years of experience in providing support to organizations in the behavioral health and human services fields. For the last 9 years, Coordinated Care Services Incorporated has provided the New York Care Coordination Program with a range of essential support services, including project management staffing, information technology, and data analysis, as well as financial management, including budget development, monitoring, and funds management.
  • Redesigning program: The program began enrolling clients in July 2002. Six months later, the steering committee realized that it still offered traditional case management, with a focus on alleviating symptoms, rather than a new practice of care coordination, with a focus on promoting recovery. As a result, the steering committee redesigned the program, redefining program activities according to the principles of "person-centered planning," a concept originally developed for use in the developmental disabilities field. The committee also adapted person-centered planning tools for use in mental health care.
  • Creating training program: Using external expertise and research, the steering committee developed a curriculum for retraining the case-management workforce to provide care coordination services based on the person-centered approach. It became clear that the new approach would only be successful if a recovery-oriented approach were embraced by the entire service system. Accordingly, training was developed to address the changes needed throughout the system with differing emphases for different professional groups and program types. Training is planned at the project level and carried out at the county level. Training varies in duration and covers topics such as person-centered care, identification of client needs and community resources, regulatory requirements, charting and billing, and developing and monitoring the effectiveness of care plans. Training includes an online workbook that allows care coordinators to practice developing care plans under different client scenarios. Program leaders created a train-the-trainer program to facilitate site-specific training in the different counties.
  • Incorporating as separate organization: In 2010, the steering committee agreed to incorporate as a stand-alone, nonprofit organization, thus enhancing its ability to apply for grant funding and codifying the commitment of the counties to each other.

Resources Used and Skills Needed

  • Staffing: The program includes approximately 185 care coordinators, with intensive case managers handling roughly 12 clients at a time and supportive case managers handling 20 to 30 (depending on the county). Case managers must meet the requirements laid out in state regulations, with intensive case managers requiring a master's degree and 2 years of experience, or a bachelor's degree and 4 years of experience, with lesser requirements for supportive case managers.
  • Costs: Intensive case management positions are funded at $76,000 to $89,000 each, inclusive of $13,600 restricted to use for client wrap-around expenses. Medicaid covers 74 percent of the cost, with state aid covering 26 percent. Supportive case management positions are funded at $69,000 - $82,000 each, inclusive of $6,800 restricted to use for client wraparound expenses. The cost for project management is approximately $450,000, with variable expenses for specific transformation initiatives such as education and training, pilots of integration of physical and behavioral health services, and pay for performance contracting for behavioral health.
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Funding Sources

New York State Office of Mental Health; Medicaid; Erie County (NY) Office of Mental Health; Onondaga County (NY) Office of Mental Health; Chautauqua County (NY) Office of Mental Health; Gennessee County (NY) Office of Mental Health; Westchester County (NY) Office of Mental Health; Wyoming County (NY) Office of Mental Health; Monroe County (NY) Office of Mental Health
Medicaid funds approximately 65 percent of the cost of the care coordinators, with the remainder being funded by State grants.end fs

Tools and Other Resources

All forms and tools (including the Quality of Life Self-Assessment tool, the Individual Service Plan, the Care Coordinator's Assessment of Functioning form, the online training workbook, a Periodic Reporting Form, and an enrollee satisfaction survey) are available at:

Adoption Considerations

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Getting Started with This Innovation

  • Design governance with consumer and provider in mind: For example, program leaders structured the steering committee to allow consumers and providers to have greater representation (and hence the ability to outvote) county representatives. This approach served to demonstrate the organization's commitment to basing decisions on what is best for consumers.
  • Adapt existing services: Care coordination services can be developed by "tweaking" existing (reimbursable) case management services, rather than creating a whole new infrastructure.
  • Create structures to promote culture change: To effectively change the philosophy and activities of care coordinators to be more person-centered and recovery-focused, county offices of mental health had to embrace overall culture change. To achieve such a change, the program created stakeholder groups (a county director group, provider group, and peer/family group) that meet on a monthly basis to discuss challenges and best practices.
  • Ensure appropriate training: To perform their jobs well, care coordinators need mentoring and training in specific skills, such as motivational interviewing and the tools of person-centered practice. Equally important, the program provided orientation and training in person-centered approaches for the full spectrum of organizations making up the service system, from state psychiatric centers to community-based treatment providers, peer organizations, and social service agencies. "Train-the-trainer" programs can also developed to reduce the need for outside trainers.

Sustaining This Innovation

  • Make sure services qualify for Medicaid reimbursement: This source of ongoing funding helps to ensure the sustainability of the program.
  • Invest in retention: The program faces high turnover among its mostly young, female care coordinators. To address this problem, program developers should consider adopting strategies to increase retention, such as flexible schedules and tuition reimbursement.
  • Seek flexible financial support: The program worked with the state to create flexible funding that supports an individualized approach to care (i.e., funds that could be used for a wide variety of purposes, such as tuition reimbursement or housing repair, rather than designated for one specific purpose).

More Information

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Contact the Innovator

Adele Gregory Gorges
Director, New York Care Coordination Program
c/o Coordinated Care Services, Inc.
1099 Jay Street, Building J
Rochester, NY 14611
(585) 613-7656

Innovator Disclosures

Ms. Gorges have not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Western New York State Care Coordination Program Web site. Available at:

Adams N, Grieder DM. Treatment Planning for Person-Centered Care: The Road to Mental Health and Addiction Recovery. Burlington, MA: Academic Press, 2004.


1 Fisher HW, Geller JL, Altaffer F, et al. The relationship between community resources and state hospital recidivism. Am J Psychiatry. 1992;149:385-90. [PubMed]
2 Klinkenberg WD, Calsyn RJ. Predictors of receipt of aftercare and recidivism among persons with severe mental illness: a review. Psychiatr Serv. 1996;47:487-96. [PubMed]
3 Walker R, Minor-Schork D, Bloch R, et al. High risk factors for rehospitalization within six months. Psychiatr Q. 1996;67:235-43. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 02, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 07, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.