Transitional Case/Care Management

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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 61 matching records.
    Service NameDescriptionLocationProgramAgency
    Abramson Center for Jewish Life - Post-Hospital Transitional CareComprehensive rehabilitative care focused on safely returning patients to their homes after a hospital stay. MontgomeryMadlyn and Leonard Abramson Center for Jewish Life - Montgomery; North WalesAbramson Center for Jewish Life
    Action Wellness - Medical Case ManagementMedical Case Managers work in partnership with clients to remove practical and emotional barriers to primary medical care, access to medications, housing, benefits and entitlements, and transportation services.PhiladelphiaAction Wellness - Philadelphia; ChinatownAction Wellness
    Action Wellness - Medical Case Management - AnnexMedical Case Managers work in partnership with clients to remove practical and emotional barriers to primary medical care, access to medications, housing, benefits and entitlements, and transportation services.PhiladelphiaAction Wellness AnnexAction Wellness
    Action Wellness - Medical Case Management - North/ Casa Nueva VidaMedical Case Managers work in partnership with clients to remove practical and emotional barriers to primary medical care, access to medications, housing, benefits and entitlements, and transportation services.PhiladelphiaAction Wellness North/ Casa Nueva VidaAction Wellness
    Action Wellness - Medical Case Management - WestMedical Case Managers work in partnership with clients to remove practical and emotional barriers to primary medical care, access to medications, housing, benefits and entitlements, and transportation services.PhiladelphiaAction Wellness WestAction Wellness
    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
    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.
    CAADC - Supportive Services for Veteran Families (SSVF)Provides a range of financial and supportive services to very low-income veterans and their families residing in or transitioning to permanent housing. Assistance can include help with rent, mortgage, or utility payments.DelawareCAADC - Delaware County; BoothwynCommunity Action Agency of Delaware County, Inc. (CAADC)
    CareLink Community Support Services - Transition Age ServicesTransition Age Services address the educational, vocational, and community living needs of 18-22 year olds. Young adults who experience mental illness often find themselves caught between systems of care that aren't designed to meet their needs. Our flexible array of psychosocial rehabilitation services including residential services, care management, and family outreach can make it possible for people to reach their goals for stable, satisfying community living.DelawareCareLink Community Support Services - DelawareCareLink Community Support Services
    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
    Critical Time Intervention - Case ManagementCritical Time Intervention (CTI)/Case Management it is an evidenced-based practice proven to reduce the number of people returning to institutions once released into the community. Case management for homeless invdividuals with mental illness is provided.MontgomeryResources for Human Development - Montgomery; Norristown (West Main Street)Resources for Human Development
    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.
    Family and Community Service of Delaware County - Permanent Supportive Housing ProgramFCS partners with the Delaware County Housing Authority by providing intensive case management services to single adults or families with children who have been homeless due to mental health or substance abuse problems.DelawareFamily and Community Service of Delaware County - Delaware; MediaFamily and Community Service of Delaware County
    Family and Community Service of Delaware County - Second Time Around Parents (STAP)STAP is a program for grandparents raising grandchildren due to parental drug/alcohol or mental health problems. Services include case management, counseling, and separate educational/support and therapy groups for grandparents and grandchildren.DelawareFamily and Community Service of Delaware County - Delaware; MediaFamily and Community Service of Delaware County
    Fellowship Health Resources - Crisis Stabilization or Step Down ProgramThe Crisis Stabilization or Step Down Program provides 24-hour residential care that provides an alternative for clients to an inpatient hospital admission or a "step down" from a hospital inpatient program. As an alternative: For clients who are experiencing an acute crisis in which the goal is to prevent inpatient hospitalization. As a step down: For clients who are ready for, or have recently been discharged from, an acute care inpatient setting, but still need services that provide transition or re-entry into the community to limit or prevent hospital stay.Chester*Main Site (Fellowship Health Resources, Inc.)Fellowship Health Resources
    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
    Holy Redeemer Health System - Drueding Center/ Project RainbowProvides transitional housing and supportive services to homeless women and their children. Supportive services include case management, counseling, and schooling support for each child.PhiladelphiaDrueding Center/ Project RainbowHoly Redeemer Health System
    International Service CenterProvides supportive services to Asians and other immigrants who speak little or no English. Services include: - Translation/Interpretation for immigrants from Southeast Asia, Bosnia, Middle East and former Soviet Union. - Can provide translation and assistance for driver's license exams for clients in Lancaster and Dauphin counties. Appointment required for special accommodations with PENNDOT. - Counseling for Southeast Asian clients in Harrisburg only. No fees. - Emergency food assistance to low income and unemployed clients in Lancaster and Dauphin Counties. No fees. - Interpretation for Southeast Asian clients in life-essential situations by appointment only. NO set limitations on area of service. Fees vary. - Translation of Southeast Asian civil status and immigration documents. No set limitations on area of service. Fees vary. - Technical assistance and training, such as peer internships, on-the-job training, consultations, lectures, and workshops. No set limitations on area of service. Appointment required. Fees vary. - Citizenship assistance for refugees. No fees. All other immigration assistance are also available to immigrants. Fees vary. DauphinInternational Service CenterInternational Service Center
    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
    Montgomery County Office of Senior Services - Nursing Home Transition Program (NHT)Nursing Home Transition (NHT) provides people with the help they need to move back to the community and then provides services to them so that they can live comfortably and safely. NHT staff will visit nursing homes to identify those people who want to move to the community. Services Include: - Finding housing - Making your home accessible - Planning your move - Personal assistance (attendant care) services - Service coordination - Transportation - Training and other services based upon your needsMontgomeryMontgomery County Office of Senior Services - Montgomery; NorristownMontgomery County Office of Senior Services
    Montgomery County Office of Senior Services - Nursing Home Transition Program (NHT) - North PennNursing Home Transition (NHT) provides people with the help they need to move back to the community and then provides services to them so that they can live comfortably and safely. NHT staff will visit nursing homes to identify those people who want to move to the community. Services Include: - Finding housing - Making your home accessible - Planning your move - Personal assistance (attendant care) services - Service coordination - Transportation - Training and other services based upon your needsMontgomeryNorth Penn District OfficeMontgomery County Office of Senior Services
    Montgomery County Office of Senior Services - Nursing Home Transition Program (NHT) - PottstownNursing Home Transition (NHT) provides people with the help they need to move back to the community and then provides services to them so that they can live comfortably and safely. NHT staff will visit nursing homes to identify those people who want to move to the community. Services Include: - Finding housing - Making your home accessible - Planning your move - Personal assistance (attendant care) services - Service coordination - Transportation - Training and other services based upon your needsMontgomeryPottstown District OfficeMontgomery County Office of Senior Services
    Montgomery County Office of Senior Services - Nursing Home Transition Program (NHT) - Willow GroveNursing Home Transition (NHT) provides people with the help they need to move back to the community and then provides services to them so that they can live comfortably and safely. NHT staff will visit nursing homes to identify those people who want to move to the community. Services Include: - Finding housing - Making your home accessible - Planning your move - Personal assistance (attendant care) services - Service coordination - Transportation - Training and other services based upon your needsMontgomeryWillow Grove District OfficeMontgomery County Office of Senior Services
    New Life Youth and Family Services - In-Home Family ServicesThe Forefront Program This community-based program provides solution-focused interventions to promote family unity and cohesion. Strength-based service interventions include: Monitoring youths’ behaviors to encourage responsible choices that enable them to remain in the community. Facilitating family-centered interagency collaboration. Assisting families in accessing appropriate levels of support services within the community. Services are designed to prevent out-of-home placement of youth or to assist in the reunification process when youth are returning home from placement. The Forefront Program supports the youth within the context of the family unit. Through a structured system of monitoring and counseling, services are created to promote the optimal acquisition of skills to improve family relationships, foster academic achievement and to gain positive community involvement through structured after-school activities or employment. SERVICES OFFERED: Two week assessment of strengths and concerns. Individualized Goal Plan. Services for a minimum of 4-6 months. Counseling occurs at home and school. Facilitation of meetings with school personnel. Daily monitoring of school attendance, academics and behavior. Coordination of structured community activities/employment acquisition. Monitoring of positive home/community adjustment. Connections to community support systems. Facilitation of interagency meetings. Weekend respite options for youth needing higher levels of accountability. COUNSELING INTERVENTIONS: Risk assessment and prevention. Strengthening family relationships. Parenting skills. Improving school performance. Developing positive social skills. Problem solving skills. Conflict management. Life Skills. Assessment by master degreed Clinical Counselor as warranted. Visitation Program WHAT is the Visitation Program? It is a service for children placed in out-of-home care. The Goal: The goal is to provide purposeful and frequent visits for children who are placed in out of home care. Through these visits Chester County Department of Children & Youth (D.C.Y.F.) will be better able to assess the family and child's needs leading to either reunification or other permanency plans. The Service Provides: A case manager to arrange visits for children and their families. Convenient locations for visits. Help in making the visit a positive experience for the child and their family. Someone to talk to concerning the visit. WHERE will the visits take place? At locations close to the birth parents (visiting sites are established in West Chester, Coatesville, Oxford and Phoenixville) at a park, recreation center or area that would be good for the child. At the parents' home or the home of their relative. At school. At any location that you, the birth parents and the worker decides appropriate. (The court may place guidelines on where visits can take place). WHEN will the visits take place? The first visit will take place as soon as possible, hopefully within 2 or 3 days of placement. Ongoing visits will take place weekly if at all possible. HOW can this work? With all our best efforts. Positive input, the hard work of the birth parents, you and the Visitation’s Staff at New Life will make visits successful.MontgomeryNew Life Youth and Family Services - Montgomery; SchwenksvilleNew Life Youth and Family Services
    New Life Youth and Family Services - West Chester Day TreatmentNew Life's West Chester Day Treatment is a therapeutic program serving adolescent males and females who have been referred Chester County Children Youth and Family, or Juvenile Probation or the students home school district. A team approach is utilized to provide individual, group, and family counseling, educational services, and independent life skills training. The goal of these services is to help the young person improve competency and accountability in the school, family and community in a manner beneficial to all. The specific goal for each student is developed individually in an Individual Service Plan. In most cases, that goal is to return to public school and graduate. CASE MANAGEMENT SERVICES -Documentation of client/family progress and treatment planning via monthly reports. -Provision of information for court/administrative reviews, school meetings and appearance at such when requested by the referring agent, parent or client -Provision of case reports for each client in accordance with state regulations EDUCATIONAL SERVICES -Students are placed in one of two self-contained classrooms (grades 7-9 and 10-12). -Older students who intend to enter the job market rather than complete their high school education are given the opportunity to prepare for the GED while completing independent life skills course material. Students preparing to go on to college are given the opportunity to prepare for SATs. COUNSELING SERVICES -Individual Counseling: Once per week for 45 minutes; additional time is provided if clients wish to see their counselor or their counselor needs to see them. -Group Therapy: Twice per week; topics are designed to raise students’ consciousness and clarify service. -Family Counseling: Once per month; additional family counseling is available if deemed necessary by the family, the counselor, or the referring agency.ChesterNew Life Youth and Family Services - Chester; West ChesterNew Life Youth and Family Services
    Next StepsFollow-up case management and aftercare for graduates of BHA housing programsDauphinBrethren Housing AssociationBrethren Housing Association
    Norristown State Hospital - Social WorkEach patient has an assigned Social Worker, who compiles a psychosocial assessment of the individual and assists him or her in resolving situational needs that arise. The Social Worker collaborates with the treatment team to develop a treatment and discharge plan, and if needed, helps each patient apply for benefits. The Social Worker is the liaison between the hospital, community and families.MontgomeryNorristown State Hospital - Montgomery; NorristownNorristown State Hospital
    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
    Northumberland County Area Agency on Aging - Nursing Home TransitionThe Nursing Home Transition Program serves nursing home residents age 18 or older who have expressed desire to transition safely back to the community, with supportive services.NorthumberlandNorthumberland County Area Agency on Aging - Nursing Home TransitionNorthumberland County Area Agency on Aging
    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
    PATH (People Acting To Help) - Adult Case Management ProgramYou will be assigned a primary case manager.. You will meet with a case manager who will form a partnership with you to facilitate your recovery. In addition to your case manager, other team members will also be available to assist you. You will meet with a case manager at your home, at PATH, or in the community. You and a case manager will identify goals that you would like to achieve and develop a plan to achieve your goals. You will receive help from a case manager to obtain mental health, substance abuse or other medical treatment. You will receive help from a case manager to obtain services such as housing, health insurance, financial benefits and other needed resources. You will be able to contact a case manager for help whenever you experience a crisis, 24 hours a day, 7 days a week. You will receive support and encouragement from a case manager as you enter recovery and learn to become more independent.PhiladelphiaPATH, Inc. CMH/MRC - Philadelphia; Northeast PhiladelphiaPATH (People Acting To Help)
    Penn Foundation - Administrative Children's Case ManagementShort term case management for children and adolescents to facilitate connection to community resourcesBucksPenn Foundation - Bucks; SellersvillePenn Foundation
    Philadelphia Veterans Multi-Service and Education Center - Supportive Service for Veteran Families (SSVF)The Supportive Services for Veteran Families (SSVF) is a new VA program which provides assistance to very low-income Veterans and their families residing in or transitioning to permanent housing. SSVF affiliates provide a range of financial assistance and supportive services designed to promote housing stability. Financial assistance can include help with back rent, mortgage or utility payments for families struggling to remain in their homes. For veterans and their families who have lost their housing, SSVF will provide financial aid with rental and utility security deposits and initial rental payments. Support services can range from assistance with transportation; child care; linkage to medical care, behavioral healthcare and recovery services for veterans experiencing PTSD and other effects of combat; and other services to help the veterans and their family re-establish financial stability and self-sufficiency.PhiladelphiaVeterans Multi-Service and Education Center - Philadelphia; Old CityPhiladelphia Veterans Multi-Service and Education Center
    Philadelphia Veterans Multi-Service and Education Center - Supportive Service for Veteran Families (SSVF) (Bucks, Chester, Delaware, Montgomery)The Supportive Services for Veteran Families (SSVF) is a new VA program which provides assistance to very low-income Veterans and their families residing in or transitioning to permanent housing. SSVF affiliates provide a range of financial assistance and supportive services designed to promote housing stability. Financial assistance can include help with back rent, mortgage or utility payments for families struggling to remain in their homes. For veterans and their families who have lost their housing, SSVF will provide financial aid with rental and utility security deposits and initial rental payments. Support services can range from assistance with transportation; child care; linkage to medical care, behavioral healthcare and recovery services for veterans experiencing PTSD and other effects of combat; and other services to help the veterans and their family re-establish financial stability and self-sufficiency.ChesterOperating Base CeciliaPhiladelphia Veterans Multi-Service and Education Center
    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
    Schuylkill People Who CareSchuylkill People Who Care offers non-medical personal assistance for mentally alert physically disabled people, between the ages of eighteen and fifty-nine who require assistance performing daily living tasks. Also offers a short-term program to help people ages eighteen to fifty-nine live independently during recuperation from an injury or hospital stay.SchuylkillSchuylkill People Who CareSchuylkill People Who Care
    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
    Valley Youth House - Adolescents Achieving Independence (AAI)Provides out-client assistance to current or former foster care youths between the ages of 14 and 21. Services provided: - Liaison between youth and school/college - Assistance locating permanent housing - Referral to job training programs - Weekly individual life skills counseling - Summer education; cultural and recreational events focusing on life skills development - Ongoing life skill development groupsMontgomeryValley Youth House - Montgomery County OfficeValley Youth House
    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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