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 24 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
    Bedford-Somerset MH-MR Transitional Case/Care ManagementDevelop, implement, assess and follow up on plans for the evaluation, treatment and/or care of people who need assistance in arranging services on an limited time basis.BedfordBedford-Somerset MH-MR Blended Case Management for Adults / BedfordBedford-Somerset MH-MR
    Bedford-Somerset MH-MR Transitional Case/Care ManagementDevelop, implement, assess and follow up on plans for the evaluation, treatment and/or care of people who need assistance in arranging services on an limited time basis.BedfordBedford-Somerset MH-MR Blended Case Management for Children and AdolescentsBedford-Somerset MH-MR
    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 - Homeless ServicesProvides homeless emergency shelter, transitional housing, help with locating and establishing a new residence, and case management. Also provides homeless veterans and their families with supportive services.JeffersonCommunity ActionCommunity 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
    Cross Keys VillageIndependent retirement living, personal care, long term nursing care, short term nursing care, adult day services, support groups for caregivers in general and for those dealing with alzheimer's/dementia, wellness programAdamsThe Brethren Home Community, Inc.The Brethren Home Community, Inc.
    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.
    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
    HCF of WarrenProvides transitional care. WarrenHCF of WarrenHCF of Warren
    New Hope Recovery RanchIndividuals will receive the same services as the New Hope Shelter, but with the addition of resources that promote freedom from addictions and victory of the self-defeating lifestyle that leads to despair and homelessness.FranklinWaynesboro New Hope ShelterWaynesboro New Hope Shelter
    Next StepsFollow-up case management and aftercare for graduates of BHA housing programsDauphinBrethren Housing AssociationBrethren Housing Association
    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
    Titusville YWCA - St. James House - Homeless ShelterHomeless shelter for women and children, case management.CrawfordTitusville YWCA - St. James HouseTitusville YWCA
    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
    YWCA of Bradford - Housing and Employment ServicesOffers safe and secure emergency housing and case management. 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 benefitsMcKeanYWCA of BradfordYWCA of Bradford

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