Uses Coleman Transition Intervention to help people after they are discharged from a health care facility. Following hospital 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 setting goes smoothly. This is a FREE service to assist people to recover, understand and manage your medications better, prevent hospital re-admissions, and plan for a follow-up appointment with your primary care physician.

Provides comprehensive substance use services such as medication-assisted treatment, case management, and individual, family, and group counseling.

The goal of case management is to optimize client functioning by providing services to individuals with multiple and complex needs. Case management helps individuals make changes to improve their life situation.

Provides community-based case management for individuals affected by brain injury. Case management includes identifying needs and developing a plan of action to meet those needs. Help individuals and their caregivers find their way through the rehabilitation process which can last for years following an injury. After determining what an individual needs and would like to accomplish, we identify and coordinate services to help them reach their goals. Monitor progress toward those goals and build partnerships and teams to create a lasting network for continued support. Primary function is to help individuals affected by brain injury return to their lives - to their homes, careers, school and communities - to the greatest extent possible.

Provides case management, assessment and direct services to elderly citizens (60+) and to adults with disabilities. Services include assessment for assisted living facility applicants and residents, participation on nursing home pre-admission screening teams, home-based services (homemaker services), referrals for adult day care and the Senior Center, investigations for Adult Protective Services and Case Management. Also provides services to adults so that they can remain in the least restrictive environment.

The Family Partner Program works together for families in Southwest Virginia to help support each individual family in service development according to their unique needs. Advocates for your family. Also affiliated with the local chapter of the Federation of Families for Children's Mental Health.

JFS offers each client an individualized Care Management plan based on a comprehensive assessment. Care Management staff will work and discuss services you would like to receive to enhance your quality of life. Once a plan is set in motion, we review it regularly to ensure your needs and expectations are being met.

Blue Ridge Behavioral Healthcare Child, Youth & Family Services Division programs offer therapeutic services and support for families of children and adolescents with, or at risk of developing serious emotional disturbance, substance use disorders, or developmental disabilities.

Assists low-income families with children up to age 6 and pregnant women with access to medical and dental services and act as a link to other human service organizations/providers in the NRV. Offers comprehensive case management in the home where children receive consistent and comprehensive care in a familiar setting. CHIP services, provided by a nurse and a home visitor team, include helping families make and keep appointments and follow physician recommendations, educational home visits, parenting education, helping families set and reach personal and family goals, transportation to medical and dental appointments, medical case management, and referrals to other community-based services to help meet the multifaceted needs of families. All services emphasize prevention and early intervention. This is not the state CHIP insurance, but will help families access Medicaid or FAMIS (state CHIP insurance). Not a substance abuse/ mental health provider but can connect families to those resources. Transports only if no other means available.

East Cary Health Center will provide services to underserved individuals throughout the Richmond region including those experiencing homelessness and housing instability, living in or around public housing, and/or living with HIV. Provides primary care, dental, and case management.

Nursing case management services are provided by public health nurses in a number of different services for adults and children. Children with elevated blood lead levels are followed to ensure they receive all needed services and follow up care. Additionally, our public health nurses provide long term care and pre-admission screening for DMAS; communicable disease investigations and services and immunization services. Some case management services are also provided to active TB cases and to Newcomer / Refugee services.

Care management aims to individualize health care to meet each patient's specific needs.

This program offers temporary assistance to at-risk, low-income families in an effort to keep them from becoming homeless. This grant program is designed to house these at-risk families as quickly as possible by providing legal counseling and financial aid for rent, utilities, moving costs, childcare and bus transportation, employment assistance and benefits counseling.

Christ House offers transitional housing to homeless men, provides intensive case management, workforce development and job coaching to increase clients' prospects of long-term financial independence and sustained housing success.

Offers instruction in independent living skills including personal finance, cooking and housekeeping, instruction in Braille keyboarding, orientation and mobility training, the use of white canes, and transportation systems. Services provided include teaching techniques that enable individuals with visual impairments to maintain and retain independence.

The goal of the SSVF Program is to promote housing stability among very low-income Veteran families who reside in or are transitioning to permanent housing. SSVF provides outreach and case management services, and will assist participants to obtain VA benefits and other public benefits. SSVF may be able to provide temporary rental and/or security deposit assistance to veterans who are at imminent risk of losing their housing while also meeting the required vulnerability targeting criteria. In order to be considered for assistance, veterans must call the SSVF Intake Coordinator at the main office line and complete the screening questionnaire. SSVF is unable to assist veterans who have a dishonorable discharge.

Comprehensive programs are designed to address older adults’ physical, emotional, and social needs, ensuring they receive the necessary support to live independently at home.

Operate the No Limits day support club and provide information and referral services to survivors of brain injury.

Provides case management for elderly Medicaid recipients. Services include assessment, development of a care plan, assistance with enrollment in public benefit programs, counseling and coordination of services. Works with families and other care providers to assure the provision of needed services which will allow elderly individuals to remain independent and in their own homes.

Child and Adolescent Services Team (CAST) help young people with mental health and substance use issues. Services include family and individual therapy, case management, crisis intervention, and coordination of other specialized services. CAST is flexible in addressing individual needs and provides services in the home, in the community at Chesterfield Mental Health Support Services. For routine Intakes, individuals are encouraged to call our main telephone number and request an Intake and Assessment.

The Youth and Family Support Services Program assists families with youth between the ages of 3-17 experiencing challenging peer and family relationships and life crises by strengthening parental and family relationships through prevention, education, and supportive case management services.

Case management team works with survivors to develop a person-centered plan for success and work with individuals to help locate and access supports in the community.

Serves senior citizens through programs and services enabling the individual to remain independent and productive. Also participates with the Hampton Roads chapter Alzheimer's Association for subsidized in-home respite care. Agency provides in home care, care coordination, transportation, congregate and home delivered meals.

Entry point for Ryan White Part B Services. Case Management and Patient Navigation services for persons living with HIV or HCV. CHARLI (Comprehensive HIV/AIDS Resources for Inmates) coordination for persons recently released from incarceration and are HIV positive.

Sponsored Residential: Program offers people with developmental disabilities a family based solution to their needs. Family Care homes provide a person-centered, family-based home in which an individual with developmental disabilities can become an active member of a family. Family based residential options for children with developmental disabilities.