PCSWNY Care Coordinators Lisa Volpe, Andrea Keogh and Teresa Spaeth work as a close knit team to provide compassionate, professional counsel and services to the clients they serve.
This is a story about a Medicaid client we’ll call “Joe”, and how he traded frequent visits to the Emergency Department for a new and more supportive home thanks to the efforts of the compassionate and dedicated Care Coordinator team from Person Centered Services of Western New York.
Person Centered Services of Western New York (PCSWNY) is a collaborative organization that was established by a group of 12 local nonprofit service providers for people with developmental disabilities. PCS’ Founding Agencies span the 17 counties throughout the Buffalo, Rochester, and Finger Lakes regions.
Bridget Bartolone, Executive Director, Person Centered Services of WNY
“Our vision is that all individuals in Region 1 with developmental and/or intellectual disabilities will have access to the residential and direct services they require,” explained Bridget Bartolone, Executive Director. “This includes care coordination, mental health and physical health – and the greatest possible choice of quality providers.”
With support from Millennium Collaborative Care, Person Centered Services (PCS) established a Care Coordination Program to directly serve clients like Joe who have a high utilization of a hospital Emergency Department ED).
“Joe was referred to our Care Coordination Program because he was utilizing the ED almost daily,” said Bridget. “By engaging with him one-on-one, our Care Coordinator was able to learn that Joe went to the ED mostly in the evening hours because he said he was lonely.”
Bridget further explained that while Joe would visit his primary care physician for scheduled appointments, he would not always complete the follow-up that was asked of him. “Joe is on several different medications and his understanding of them is minimal,” she added. “Joe also did not have many positive natural supports in his life. So, he really benefitted from the compassion and concern of our Care Coordinator.”
Alicia Fellows, Director of Care Coordination, Person Centered Services of WNY
“Once formally referred to Person Centered Services of Western New York’s Care Coordination Program, Joe was assigned a Care Coordinator and she started to work with him to gain a better understanding of his medications and encouraged him to complete the follow-up that was asked of him, to be able to work towards improving his health,” explained Alicia Fellows, PCS Director of Care Coordination.
“Joe’s Care Coordinator also took the lead to be the primary means of communication between his support staff, MSC and Community Habilitation Services. She worked with his support team to determine and help them understand what would lead up to him utilizing the ED; and also helped coordinate the assistance he would need with his appointments. And to ensure they were prioritized based on need.”
Alicia further explained that many times, the topic of supported housing was approached with Joe as a way to provide him more support in the evening.
“At first, Joe was very hesitant to tour different housing options,” said Alicia. “However, with the support of his MSC/Care Coordinator, he was willing to tour a few different houses, and after a long process, he found a good fit and agreed to start the process of moving.:”
PCSWNY Care Coordinators Lisa Volpe, Andrea Keogh and Teresa Spaeth share what they learned from the assistance provided to Joe.
What have we learned from Joe’s story? Since connecting with a PCSWNY Care Coordinator and moving into his new home, his ED visits have continued to decrease and his medical needs are being addressed and followed-up on. And perhaps most important, Joe is now a lot less lonely and therefore more firmly on the road to improved health and overall well being.
About Person Centered Services of Western New York
Person Centered Services of Western New York (PCSWNY) is a collaborative organization established by a group of twelve local nonprofit service providers for people with developmental disabilities. Founding Agencies span the 17 counties throughout the Buffalo, Rochester, and Finger Lakes regions include:
Able2, formerly Cerebral Palsy and Handicapped Children’s Association of Chemung County has been the premier provider of comprehensive services to people with developmental disabilities. Today, they are serving hundreds of children and adults along with their families from Chemung County and surrounding areas.
Aspire’s mission is to support children and adults with developmental and similar disabilities, helping them to live their lives to the fullest by providing individualized assistance based on personal choices. Aspire envisions full participation of those we support in all aspects of community living. Toward that end, Aspire empowers individuals to maximize their potential, including those we support, those who work for us, and those who work with us.
Baker Victory Services is dedicated to fostering the highest possible quality of life and personal achievement by partnering with children, adults, their families and the community. Programming includes services for the developmentally disabled, residential facilities for youths with behavioral and mental health challenges, full-day special education programs, clinical and mobile dental services, adoption, and foster care coordination.
The Cantalician Center provides person-centered compassionate services that promote independence, and offers meaningful opportunities to 350 individuals annually with developmental disabilities, from birth through adulthood. Programs include daycare, preschool, elementary and secondary school age programs, adult day habilitation, supported employment, family centered evaluations, and Medicaid Service Coordination.
For more than two decades, Community Services for the Developmentally Disabled has been known for passionate professionals and creative services that help each person achieve their personal dream. We offer more than 40 different programs, and will help you design a plan to reach your personal, social, housing and vocational goals.
Heritage Christian Services supports more than 1,700 children and adults with disabilities. The agency operates more than 70 neighborhood homes, service coordination, respite, community habilitation and 26 day programs, and has been recognized by the Office for People With Developmental Disabilities as one of New York State’s top service providers to people with special needs.
Founded 175 years ago, Hillside Family of Agencies provides child welfare, mental health, youth development, juvenile justice, special education and developmental disabilities services to 12,636 youth and families across central and western New York, and Prince George’s County, MD.
Holy Childhood, a non-denominational school and agency serving greater Rochester, has enriched the lives of people with developmental disabilities for more than six decades. Preparing children and adults with skills which lead to maximum independence and lifelong success, Holy Childhood provides individualized school, day program, clinic and respite services.
Based in Rochester, New York, Lifetime Assistance offers a full spectrum of premier developmental disability services. Strongly rooted in person-first services since 1978, Lifetime remains passionate about supporting individuals as successful participants in a respectful and inclusive community.
Pathways provides children, adults and families with specialized programs and services in developmental disabilities, mental health, family support, traumatic brain injury, nursing home alternatives, home care and child care. We hold ourselves accountable for meeting the expressed needs of those we support and for offering them meaningful opportunities to develop their own capabilities.
People Inc. is Western New York’s leading non-profit human services agency. Through a variety of services including residential, employment, community outreach, health care and recreation programs, we help seniors, families and people with disabilities live more healthy, independent and productive lives. As an OPWDD Compass agency, People Inc. provides services to more than 10,000 individuals throughout Western New York.
SASi, is a leading non-profit human services agency that provides quality services to adults and children with special needs and their families. The organization focuses on the unique skills, desires, needs and goals of each person and works toward those goals through specialized programs and services, constantly striving to provide experiences that enhance individual opportunities and enrich their lives.
The Future is Here…
To ensure conflict free care management and to provide better healthcare, the Office for People with Developmental Disabilities (OPWDD) is changing how service coordination is provided.
Effective July 1, 2018 Medicaid Service Coordination will be replaced by Care Coordination delivered by I/DD Health Homes across New York State. Prospective I/DD Health Homes are currently submitting applications to begin service on July 1, 2018.
The founding PCSWNY agencies are joining forces with the Arc Collaborative, and a few high quality independent provider agencies to form Person Centered Services Care Coordination Organization (PCS CCO). If approved as an I/DD Health Home, PCS CCO will coordinate care for roughly 19,000 individuals across OPWDD Region 1. PCS CCO will leverage the learnings and accomplishments achieved through the care coordination demonstration project that helped “Joe” envision and embark on a better future.
MEET THE TEAM: Person Centered Services of WNY
Bridget Bartolone, Executive Director
Bridget Bartolone joined Person Centered Services of WNY in 2013 as the Executive Director. She works directly with the Board of Directors, and in partnership with the Board, has developed the short and long term Strategic Plan. Bridget guides the organization through the daily operations with a focus on preparing the Agencies for the upcoming changes to the field of Developmental Disabilities relative to Care Coordination and evolving reimbursement methodologies.
Bridget comes to PCSWNY from HealthNow NY, the parent company of Blue Cross Blue Shield of WNY and Blue Shield of NENY, where she held two different senior leadership positions during her three year tenure with the company. She was Vice President of Operations Transformation, and the Vice President of the General Business. Before joining Blue Cross and Blue Shield, Bridget held numerous leadership positions at Eli Lilly and Company, a global pharmaceutical organization. She started in sales in 1998, and had a variety of leadership roles across Lilly USA over the course of 13 years. She is also one of the original Six Sigma Black Belts at Lilly, when it deployed Lean Six Sigma in 2005.
Bridget has a Bachelor of Science in Health Management and Policy from the University of New Hampshire and a certificate of Executive Leadership from Cornell University. She serves on a several committees and boards in Buffalo, where she resides with her husband and two daughters.
Kellie Earsing, Care Coordination Manager
Kellie has been employed by Community Services for the Developmentally Disabled since 2004. Kellie has held a variety of positions with Community Services including: Habilitation Instructor, MSC for Parents & Youth, MSC Regulatory Specialist, Compliance Specialist , Service Coordination Program Manager and currently holds the position of Service Coordination Program Coordinator. Kellie received her Bachelor of Science in Sociology from Buffalo State College in 2003.
Alicia Fellows, Director of Care Coordination
Alicia Fellows has extensive experience working in the DD field, and has worked at Community Services for the Developmentally Disabled for the past 15 years. During her time with CSDD she has worked with families and the child welfare system, with dually diagnosed individuals, and supervised a Specialized Case Management program for 7 years which provides services to individuals involved with or at risk of being involved with the criminal justice system.
As the Director of Care Coordination for PCSWNY, Alicia oversees development of the PCSWNY care coordination model. She holds a Master of Social Work from the University at Buffalo.
Kelly Lincoln, Director of Operations
Kelly Lincoln joined PCSWNY as an independent contractor in February 2015. She is working alongside other PCS project staff to develop a care coordination model for the developmentally and intellectually disabled.
In addition to this work, Kelly leads the operational development of a senior focused care coordination model, and consults with families who are trying to navigate various social, medical, legal, and financial resources for their elderly loved ones.
Kelly has a professional background in the managed care industry, and an Master of Business Administration from the University at Buffalo.
Linda Golden, Director of Quality Control
Linda has over 32 years experience in the field of social work and currently oversees her own private practice as a mental health therapist in the Rochester, NY vicinity. Linda has previously served as the Director of both a community mental health clinic, and an Inpatient Hospital program for addiction and co-occurring disorders. She has also served as the Director of Quality Assurance for mental health and addiction housing programs, and as an Emergency care psychiatric assignment officer.
Linda holds a Bachelor of Social Work from SUNY Brockport, and a Master of Social Work from University of Buffalo.