Transitional Services for New York Inc.

Behavioral Health Care Coordination

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TSINY’s Behavioral Health Care Coordination Program provides care management to individuals with serious mental illness and/or chronic health conditions. The program goal is to assist individuals in improving wellness and encourage coordinated access to community-based healthcare while preventing avoidable use of emergency room and inpatient healthcare. Care Coordinators assess the individual person’s physical health, mental health, substance abuse, and social service needs and work with each person to develop an integrated plan of care to address each need. The Care Coordinator also helps individuals manage their plan of care by accessing appropriate services, facilitate communication across health care providers and assist the person in following the plan of care.

The following services are provided:

  • Comprehensive care management
  • Care coordination and health promotion
  • Comprehensive transitional care from inpatient to other settings with appropriate follow-up
  • Individual and family support, which includes authorized representatives
  • Referral to community and social support services

Criteria for Admission

To be admitted for services, an individual must be at least 17½ years old and meet one of the following three conditions:

  1. A serious mental illness
  2. Two chronic conditions (e.g., mental health condition, substance abuse disorder, asthma, diabetes, heart disease, BMI over 25 or other chronic conditions)
  3. One qualifying chronic condition (HIV/AIDS) and the risk of developing another.

Program Hours

Monday through Friday: 8:30 AM – 5:30 PM.

After-hours coverage is also available for recipients in a crisis situation.
For more information, please contact the Program Director.

Behavioral Health Care Coordination

90-27 Sutphin Boulevard
5th Floor
Jamaica, New York 11435
Tel: (718) 526-8400 ext. 7186
Fax: (718) 297-8658