Adult Care Coordination of Northern New York

Adult Care Coordination of Northern New York


The Children’s Home provides Care Coordination services to adults living in Jefferson County. Services include Strength-Based Assessments, Individualized Service Planning, Care Coordination, and Transition Planning.


The goals of care management services are to reduce the risk of long-term inpatient treatment, and minimize the use of emergency services, link adults to community-based services and support systems.


If you are receiving Medicaid, Medicaid Managed Care, or are Medicaid eligible, reside in Jefferson County and have been diagnosed with a chronic medical condition or have mental health concerns, you may qualify for services. If you meet the eligibility criteria above and would like to enroll in the Care Coordination Program, please contact the Outreach Coordinator at (315) 777-9713. The Care Coordination Program is dedicated to working with you to ensure all your health care needs are met and you have the opportunity to live a healthy, fulfilling life.


  • Strength-Based Assessments: To help the person identify strengths and needs, Care Coordinators sit with each person and complete an assessment.
  • Individualized Service Plans: With the broad goal of enhancing the quality of life, based on the results of the assessment process, Care Coordinators assist the person in developing a plan of action specific to their unique circumstances which uses strengths to address identified needs.
  • Care Coordination: Care Coordinators link the person to community-based services identified in the Individualized Service Plan.
  • Transition Planning: As part of the planning process, Care Coordinators work with the person to ensure a plan is also in place which will help them continue accessing needed services and supports as they transition out of Care Coordination Services.


  • Medical Services
  • Mental Health Services
  • Housing
  • Self-help and Support
  • Specialty Services
  • Home Care and Nursing
  • Financial Education
  • Educational Services
  • Food and Shelter
  • Any other identified area of need


Adult Case Management Services were first introduced in Jefferson County in 2001. These services were provided through the NYS New Initiatives Funding program aimed at reducing the risk of long-term inpatient treatment and use of emergency mental health services by adults living in New York State.

In 2004 the Children’s Home was awarded the contract to provide Case Management Services to adults living in Jefferson County. Children’s Home Case Managers work with adults in developing and utilizing community supports that directly impact their ability to avoid inpatient hospitalization and reduce the need for emergency mental health services.

In 2013, Case Management Services for adults with mental health issues transitioned into Care Management with a focus on comprehensive health care for adults with chronic conditions and to assist them to live a healthy, fulfilling life.


Jefferson County’s Single Point of Entry (SPOE) is the process whereby adults are linked to services which best meet their needs. The SPOE process is specifically designed to serve individuals 18 years of age or older who are seriously and persistently mentally ill.

Jefferson County maintains an open referral system. Eligible adults can make a self-referral or can have another person, such as a family member or health care professional complete the referral on their behalf. Referrals for services are sent to the SPOE Coordinator who gathers information by reviewing applications and conducting intake interviews with the individual. The SPOE Coordinator then presents the information to the SPOE Committee.

The SPOE Committee consists of representatives from area service providers who meet each month to review the intake information and make a determination regarding the person’s eligibility for services and appropriate level of care. The individual and any representative at their discretion are encouraged to attend and actively participate in the SPOE Committee meeting. Through this process, appropriate community-based service providers are identified and assigned to assist the person in meeting identified needs.

For More Information:

Children’s Home of Jefferson County
P.O. Box 6550
Watertown, NY 13601
Phone: 315-777-9713
Fax: 315-777-1726

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Administrative Offices

P.O. Box 6550
1704 State Street
Watertown NY 13601
Phone: 315-788-7430
Fax: 315-785-5637