Transitional Case/Care Management

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    The structure of the services index and definitions of the terms contained herein were originally published in A Taxonomy of Human Services: A Conceptual Framework with Standardized Terminology and Definitions for the Field by the Information and Referral Federation of Los Angeles County, Inc., 3035 Tyler Ave., El Monte, CA 91731; Copyright (c) 1983, 1987, 1991. No part of this listing of human services terms and definitions may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electrical, mechanical, photocopying, recording or otherwise without the prior written permission of the Information and Referral Federation of Los Angeles County, Inc.

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    Taxonomy Code: PH-1000.8500

    Programs that develop, implement, assess and follow up on plans for the evaluation, treatment and/or care of people who are experiencing a specific, time-limited problem such as a transition from hospitalization to independent living and who need assistance to obtain and coordinate the support services that will facilitate the change.

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    There are 40 matching records.
    Service NameDescriptionLocationProgramAgency
    Alcohol and Drug Abuse Services - Bradford - Central Intake/AssessmentProgram provides drug & alcohol services to include prevention, intervention, outpatient, case management, recovery support, and community based services. Also provides gambling outpatient treatment.McKeanAlcohol and Drug Abuse Services - BradfordAlcohol and Drug Abuse Services
    Alcohol and Drug Abuse Services - Emporium - Central Intake/AssessmentProgram provides drug and alcohol services to include prevention, intervention, outpatient, case management, recovery support and community based services. Also provides gambling outpatient treatment. CameronAlcohol and Drug Abuse Services - EmporiumAlcohol and Drug Abuse Services
    Alcohol and Drug Abuse Services - Kane - Central Intake/AssessmentProgram provides drug and alcohol services to include prevention, intervention, outpatient, case management, recovery support and community based services. Also provides gambling outpatient treatment. McKeanAlcohol and Drug Abuse Services - KaneAlcohol and Drug Abuse Services
    Alcohol and Drug Abuse Services - Port Allegany - Central Intake/AssessmentProgram provides drug and alcohol services to include prevention, intervention, outpatient, intensive outpatient, case management, recovery support and community based services. Also provides gambling outpatient treatment. McKeanAlcohol and Drug Abuse Services - Port AlleganyAlcohol and Drug Abuse Services
    Alcohol and Drug Abuse Services - Ridgway - Central Intake/AssessmentProgram provides drug and alcohol services to include prevention, intervention, outpatient, intensive outpatient, case management, recovery support and community based services. Also provides gambling outpatient treatment. ElkAlcohol and Drug Abuse Services - RidgwayAlcohol and Drug Abuse Services
    Alcohol and Drug Abuse Services - St. Marys - Central Intake/AssessmentProgram provides drug and alcohol services to include prevention, intervention, outpatient, intensive outpatient, case management, recovery support and community based services. Also provides gambling outpatient treatment. ElkAlcohol and Drug Abuse Services - St. MarysAlcohol and Drug Abuse Services
    Allegheny County DHS - Allegheny LinkThe Allegheny Link connects people in need to available resources in an effort to maintain their independence and quality of life. The Allegheny Link assists: - people with disabilities to find needed resources - older adults to remain in the community - people who are homeless or at risk of homelessness to reach the goal of stable housing - parents and caregivers of children 0-6 by connecting them to home visiting programsAlleghenyOffice of Community ServicesAllegheny County Department of Human Services
    BHC, Cross Keys VillageResidential living for those seeking a wide range of independent living services in a senior community. An unrivaled range of personal services include: • Personal care • Adult day services • In-patient rehab • General health care • Memory support A nationally accredited Continuing Care Retirement Community.AdamsBrethren Home Community, Inc. (BHC)Brethren Home Community, Inc.
    Care Transitions Program - Wayne County Area Agency on AgingAims to help people who are discharged from a health care facility. Following discharge, patients often require care from different medical professionals in many different settings. This program is designed to improve the continuity of care for persons with chronic conditions across different health settings and ensure that each transfer between settings goes smoothly. This 4 week service is free and is in conjunction with Wayne Memorial Hospital.WayneWayne County Area Agency on AgingWayne County Area Agency on Aging
    Case Management and Life Skills Training - Clinton County Housing CoalitionClients are eligible for case management for up to twelve months. Life Skills Training includes both in-house counseling and links to community service agencies for assistance. Major topics include: Obtaining & Maintaining Housing Job Search & Workplace Skills Budgeting Mental Health Counseling Addiction Counseling Nutrition & Healthy Living Practices Parenting Skills Disability Claims NavigatioNClintonClinton County Housing CoalitionClinton County Housing Coalition
    Catholic Charities of the Diocese of Pittsburgh - Intensive Case ManagementTo promote awareness of the resources that are available in the county. Provides case management/case work services. Provides referrals and assists with accessing the available resources in the County. Provides follow up calls to make sure that the appropriate resource was used.AlleghenyCatholic Charities of the Diocese of Pittsburgh, Inc. Counseling ServicesCatholic Charities of the Diocese of Pittsburgh, Inc.
    Children's Aid Society in Clearfield County - Family Support ServicesThrough case planning with the family and referral agency staff we will provide short-term, time limited and family focused services designed to teach the necessary skills identified in the assessment. All approaches are strengths-based, addressing challenges, stabilizing families and enhancing family functioning to assist the family to remain intact. Healthy Parenting and Discipline Instruction and Supervision, Communication and Relationship Skill Development, Housing/Physical Home Needs, Networking with Community Resources, Budgeting/Money Management, Crisis Intervention, Visit Supervision, Health Care Assistance, Transportation, Older Youth Intervention, Employment Services, Reunification support.ClearfieldChildren's Aid Society in Clearfield CountyChildren's Aid Society in Clearfield County
    Children's Aid Society in Clearfield County - Real RelationshipsFree relationship education services for couples and individuals. Classes, retreats, and workshops include free meals, gas cards, access to other programs and services, and case management.ClearfieldChildren's Aid Society in Clearfield CountyChildren's Aid Society in Clearfield County
    ComForcare Home CareComForcare strives to improve the quality of life and level of independence for every client and family receiving our services. ComForcare employs highly trained caregivers who provide a wide range of comprehensive services including: -bathing, grooming, and hygiene -transfers and ambulation -meal preparation -medication adherence -transportation/errands -chore services and light housekeeping -family respite -reducing hospital and rehabilitation re-admissions by partnering with healthcare professionals to ensure discharge instructions are fully executed and educate clients on the self management of their condition.YorkComForcare Home CareShiloh Homecare Corporation
    Community Action - Main Office - Homeless Services (CoC Coordinated Entry)Provides homeless emergency shelter, transitional housing, help with locating and establishing a new residence, and case management.JeffersonCommunity Action - Main OfficeCommunity Action
    Crawford County Mental Health Awareness Program - Housing Solutions - Community Support ServicesProvides case management in addition to utility assistance, employment aid, and short-term transportation assistance.CrawfordCrawford County Mental Health Awareness Program - Housing SolutionsCrawford County Mental Health Awareness Program
    Erie County Veterans Affairs Medical Center - Transition and Care Management ProgramA social work program designed to help Veterans seamlessly transition from military life in the DOD to civilian life connecting them with VA healthcare. This program can assist post 9/11 veterans with completing health and wellness goals to ease transition back into civilian life by providing navigation assistance of the VA system and appropriate referrals to community resources.ErieErie County Veterans Affairs Medical CenterErie Veterans Affairs Medical Center
    Experience, Inc. - Nursing Home Transitional CareThis service enhances the opportunities for nursing facility residents who express the desire to relocate from the facility back into the community.WarrenExperience, Inc.Experience Inc.
    Fayette County Drug and Alcohol Commission Case ManagementProvides case management for inpatient treatmentFayetteCase ManagementFayette County Drug and Alcohol Commission
    Glade Run Lutheran ServicesTransitions is a hands-on program for teens and young adults ages 14-21 with autism spectrum disorders. Transitions focuses on social skills, independent living, and vocational skills with students during a school day to prepare them for successful independent living.ButlerGlade Run Lutheran Services Autism ServicesGlade Run Lutheran Services
    Greene County Human Services - Intellectual and Developmental DisabilitiesPromotes opportunities for individuals with disabilities to lead full and productive lives within the community. Ensures that services and supports are provided to meet the needs of consumers with intellectual disabilities in the least restrictive setting possible.GreeneIntellectual and Developmental DisabilitiesGreene County Human Services
    HCF of WarrenProvides transitional care. WarrenHCF of WarrenHCF of Warren
    Lycoming/Clinton MH/ID - Mental Health Services - Williamsport OfficeMental health services are primarily available for adults with a serious mental illness, characterized by a diagnosis of a psychotic disorder and/or a major mood disorder of long duration with intermittent periods of wellness and illness, and children or adolescents with or "at risk" of developing a serious emotional disturbance. An assessment Unit provides or connects clients with appropriate services. The case management staff provides ongoing support to the individual and the family. Contracted provider agencies offer a variety of general and intensive services in the community. 24-hour crisis intervention also available.LycomingLycoming/Clinton Mental Health/Intellectual Disabilities Program(MH/ID) - Williamsport OfficeLycoming/Clinton Joinder Board
    Mon Yough Community Services - Children and Adolescent Service CoordinationProvides comprehensive, quality mental health services to children, adolescents, and their families in order to assist them in achieving success in their lives. Mental health treatment is offered on an individual, family, or group basis.AlleghenyMon Yough Community ServicesMon Yough Community Services
    Mon Yough Community Services - Service CoordinationPromotes self-sufficiency, self-determination, and stable community living among consumers of mental health services. Provides individuals with access to needed services and supports. Acts as an advocate on behalf of consumers. Includes two levels of Administrative Service Coordination (ASC) and Targeted Service Coordination (TSC). Administrative Service Coordination is available as needed for individuals who are managing community living on their own. Targeted Service Coordination is available to those who have more complex needs and challenges with community living.AlleghenyMon Yough Community ServicesMon Yough Community Services
    Next StepsFollow-up case management and aftercare for graduates of BHA housing programsDauphinBrethren Housing AssociationBrethren Housing Association
    Northern Tier Community Action Corporation - Potter County Homeless Prevention ProgramProvide case management with financial assistance for qualified low-income families affected by the reduction of available rentals and increased rental costs impacted by the Marcellus drilling in Potter County.CameronNorthern Tier Community Action CorporationNorthern Tier Community Action Corporation
    Northern Tier Community Action Corporation - Referral/Case ManagementAll individuals participating in programs at Northern Tier participate in a needs assessment evaluation to determine immediate needs and prioritize how we might provide assistance. From this needs assessment a mutually agreed upon action plan is developed to establish goals and guide the client and the case manager. As part of the goals established, Case Managers will work with the family to develop a monthly cash flow and money management plan. Case Managers will work with individuals and families to develop and increase job seeking and employability skills to increase the potential for employment and self-sufficiency.CameronNorthern Tier Community Action CorporationNorthern Tier Community Action Corporation
    Nursing Home Transition Services - Roads to Freedom Center for Independent Living of North Central PANursing Home Transition provides alternatives to nursing home care to individuals’ ranging from 18 to 59 years of age by providing opportunity for individuals and their families or caregivers to be fully informed of all long-term living options, including the full range of home and community-based services. Participants receive the guidance and support needed to make an informed choice about their long-term living services empowering consumers who want to move to a home and community of their choice.ClintonRoads to Freedom - Independent Living ProgramRoads to Freedom Center for Independent Living of North Central PA
    POWER Residential TreatmentA 25-bed residential treatment facility serving women working hard to reclaim their lives from the devastation of untreated chemical dependency. Services include: assessment, individual therapy and group therapy, creative writing, drug & alcohol educationAlleghenyPOWERPennsylvania Organization for Women in Early Recovery
    Ruth's Way, Inc.Provides consulting services to female youth ages 13-21. Utilizes Achievement Consultation to help girls to grow into successful women. Key areas of focus within this process are Family Development, Care Coordination, Life Coaching, Life Skills, Job Development, Job Readiness/Employment Soft Skills, Counseling and Mentoring for girls and their families.AlleghenyRuth's Way, Inc.Ruth's Way
    Titusville YWCA - St. James House - Homeless ShelterHomeless shelter for women and children, case management.CrawfordTitusville YWCA - St. James HouseTitusville YWCA
    Transitional Care - Senior Helpers SunburyMakes the transition from a hospital or long term care facility to home easier with Staying Home Safe™ - a unique approach to care management that is built around patient goals and creating a safe environment for recuperation.NorthumberlandSenior Helpers SunburySusquehanna Seniors, LLC dba Senior Helpers
    Union-Snyder Agency on Aging - Long Term Care AssistanceAssessment services to determine nursing home or assisted living placement and related services. Creation of a care plan oversite to ensure that the individual’s changing needs are met. Assistance and support for consumers who want to move from a nursing home back to the home of their choice in the community.SnyderUnion-Snyder Agency on Aging, Inc.Union-Snyder Agency on Aging, Inc.
    United Cerebral Palsy of Central PA - Selinsgrove - Case/Care ManagementSnyderUnited Cerebral Palsy of Central PA - SelinsgroveUnited Cerebral Palsy of Central PA
    United States Army Warrior Transition Command - Warrior Care and Transition ProgramThe U.S. Army Warrior Transition Command (WTC) is the lead proponent for the Warrior Care and Transition Program (WCTP), which evaluates and treats wounded, ill and injured Soldiers through a comprehensive, Soldier-centric process of medical care, rehabilitation, professional development and achievement of personal goals. Major elements of the WCTP include:
    • Warrior Transition Units (WTUs) - provide command and medical management assistance to Soldiers as they navigate the Army’s medical treatment system to successfully reintegrate back into the force or transition from the Army.
    • U.S. Army Wounded Warrior Program (AW2) – Assists severely wounded, ill and injured Soldiers, Veterans and their Families throughout their recovery and transition.
    • Comprehensive Transition Plan (CTP) – The CTP is a six-part multidisciplinary process that includes an individual recovery plan that the Soldier customizes and builds with the support of his/her Triad of Care and Family.
    • Triad of Care – Each WTU Soldier benefits from a squad leader, nurse case manager, and primary care manager assigned to a WTU.
    • Interdisciplinary Team – The Triad of Care is augmented by an interdisciplinary team of health care and transition specialists who work together to coordinate and optimize the care and transition of each individual Soldier.
    • Career and Education – WTUs help the Soldier establish short-term and long-term career goals and identify opportunities to enhance existing skills or develop new ones based on the Soldier’s transition track, whether it is remaining in the Army or transitioning from the Army to civilian status.
    • Internships – Helps Soldiers prepare for civilian employment by helping identify internship opportunities to augment a Soldier's transition.
    • Health and Recovery – Provides helpful resources on access to medical care and adaptive reconditioning options to help Soldiers achieve their health, fitness, wellness, and resilience goals.
    • Understanding IDES – WTUs assist Soldiers in understanding and maneuvering the U.S. Army Physical Disability Agency’s (USAPDA) Integrated Disability Evaluation System (IDES). IDES includes the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB), which determine whether or not wounded, ill and injured Soldiers can continue to perform their duties with their medical condition(s).
    • Access to SFAC and Other Resources – Soldier and Family Assistance Centers (SFACs) are located at most MTFs to serve Soldiers and their Families. The SFACs offer most of the services available throughout the installation in a central location and can coordinate other services as-needed.
    United States Department of the Army, United States Army Warrior Transition CommandUnited States Department of Defense
    United States Department of the Army, United States Army Warrior Transition CommandThe United States Army Warrior Transition Command (WTC)serves an essential role, not only in managing the care and recovery of Soldiers evacuated from theater, but also those preparing to deploy and those who have returned from combat that require complex care management to cope with the effects of war and multiple deployments. WTC works to ensure everything possible is done to enable Soldiers to return to duty. WTC also plays an important role in ensuring Reserve Component Soldiers receive the care they require prior to and after deployment to remain mission ready.United States Department of the Army, United States Army Warrior Transition CommandUnited States Department of Defense
    Unity Family Services Case ManagementThe treatment team serves as the family’s case manager. As such, the treatment team’s responsibilities include assessment, planning, service linkage, advocacy, procuring goods and services, and referrals.ArmstrongUnity Family Services Family Based ProgramUnity Family Services
    Venango County Department of Human Services - Main Complex - Drug and Alcohol Program Case ManagementCase management will help individuals with non-treatment needs such as housing, transportation, or childcare, that may be a barrier to treatment. A service coordinator will guide the individual through a continuum of service including step-down programs and a certified recovery specialist.VenangoVenango County Department of Human Services - Main ComplexVenango County Department of Human Services
    YWCA of Bradford - Housing and Employment ServicesOffers safe and secure emergency housing and case management. Offers help with homelessness. Has a homeless shelter. Case Management: Program staff assist individuals with, obtaining safe, affordable, and permanent housing, job searches, resume preparation, employment readiness, learning how to budget and skills of daily living, applying for social security benefits, street outreachMcKeanYWCA of BradfordYWCA of Bradford

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