Care Coordination Services

Advances in medicine and technology have enabled children and young adults with chronic conditions and medical complexity to live longer, more fulfilling and productive lives than ever before.

St. Mary’s recognizes the enormous day-to-day challenges of chronic conditions and medical complexity. We understand that in addition to families having to learn how to care for their loved ones, they also need to figure out how to access services, navigate multiple complex systems, and find support.

St. Mary’s Care Coordination Services assists families with finding the best support to achieve a quality of life at home and in the community.

Skilled care coordinators will assist families with meeting the medical, social, developmental, educational, and financial needs of their child or young adult with a chronic condition and/or medical complexity.

St. Mary’s skilled Care Coordinators assist eligible individuals & their families with:

• Access to community support & services
• Private Duty Nursing
• Home Health Aides
• Consumer Directed Personal & Assistance Program (CDPAP)
• Therapies
• Educational Services
• Benefits/Entitlements
• Home and Vehicle Modifcations
• Family Supports
• Transitional Care(Early Intervention, Preschool, School Age, & Young Adult Services)

Optimal Care Coordination results in:

• Greater access to community services and resources
• Greater capacity to navigate systems
• Knowledge to achieve and maintain quality of life
• Improved skills for patient/family advocacy and empowerment

St. Mary’s Care Coordination Services are provided through the following programs:

• Pediatric Health Homes

Service areas:

• NYC-5 boroughs
• Nassau
• Suffolk