A-SPOA Service Providers & Referral Information
THRIVE Wellness and Recovery – Community Residence
Services: This program assists residents in coordinating and accessing needed services within the community, such as behavioral health and medical services, substance use services, employment, and day programming. Specialized services are provided by Qualified Mental Health Staff & Professionals, including completing assessments, and person-centered strength-based creation of individualized action plans to meet residents’ needs and goals. Staff work together with residents and community providers to ensure continuity of care. These THRIVE staff also provide targeted one-on-one rehabilitation services to increase independent living skills to assist in the transition to independent community living.
Locations: Watertown, Gouverneur and Clayton.
Eligibility: Adults 18+ with serious mental illness requiring 24-hour supervision and support. Must be able to participate in community-based treatment.
When to Refer: Client needs 24-hour supervision, is homeless or unstably housed, transitioning from higher level of care, or needs assistance with medication management and daily living activities.
THRIVE Wellness and Recovery – Treatment Apartment Program
Program Description: The Apartment Treatment Program (ATP) operated by THRIVE Wellness and Recovery is a New York State Office of Mental Health (OMH)–licensed residential treatment program for adults with serious and persistent mental illness.
Services: The Apartment Program provides temporary rental assistance, furnishings, and intensive case management for adults with a serious mental illness or significant functional impairment. The program helps individuals secure and maintain safe, high‑quality, long‑term affordable housing while building skills for successful independent living. Staff offer goal‑oriented, person‑centered support including housing setup, medication management, daily living skill development, and connection to community resources such as employment services, mental health and substance use treatment, and transportation. Residents receive 24/7 on‑call support, participate in monthly activities, and work with staff to create individualized, strengths‑based action plans that promote stability and independence.
Apartment Locations: Jefferson County.
Eligibility: To be eligible for the Apartment Treatment Program, an individual must: Be 18 years of age or older; Have a primary diagnosis of a serious and persistent mental illness; Be appropriate for a certified apartment-based level of care; Be willing to participate in a collaboratively developed individualized service plan; Have a physician verify eligibility for the program. Additional considerations: Referrals may be made by mental health providers, case managers, or self-referrals. Residents must be able to live in an apartment setting with support.
When to Refer: An individual may be referred to the Apartment Treatment Program if they: Need structured mental health support but do not require 24-hour staffed congregate care; Are transitioning from psychiatric hospitalization, Community Residence or higher level of care, or unstable or unsafe housing; Would benefit from support with medication management and appointment coordination, daily routines and self-care, budgeting, grocery shopping, and cooking, benefits management, developing coping skills and relapse prevention; Are working toward improved mental health stability, substance use recovery, employment, education (GED/college), or vocational goals, increased community involvement and social connection; Would benefit from regular staff contact, peer support, groups, recreational outings, and social opportunities; Need a least-restrictive, recovery-oriented residential setting with crisis support available 24/7.
THRIVE Wellness and Recovery – Supported Housing
Services: Supportive Housing provides person‑centered, safe, and affordable housing options designed to promote long‑term stability. Each individual is paired with a Housing Case Manager who helps identify barriers, develop a personalized Housing Support Plan, understand tenant rights, and get settled into housing. Ongoing rental support is provided according to program guidelines, along with referrals to additional services that build independent living skills and support successful community living.
Eligibility: In order to be eligible, an individual must be at least 18 years of age, have a primary diagnosis of serious mental illness (SMI) and experience substantial impairments in maintaining safe and secure housing.
When to Refer: Client is ready for independent living with supports, has barriers to housing due to mental illness, needs affordable housing with built-in services, or is stepping down from more intensive residential care.
THRIVE Wellness and Recovery – Transitional Safety Unit Program
Services: The Transitional Safety Unit Program provides short‑term housing and supportive services for individuals with a substance use disorder who are homeless or at risk of homelessness and exiting a residential treatment program or the criminal justice system. The program offers rental subsidies, furnished studio or one‑bedroom units, and staff support to help residents maintain recovery while permanent housing is secured.
Eligibility: Adults with a substance use disorder who are experiencing homelessness or unstable housing and are exiting a residential treatment program or the criminal justice system. Units are available in Jefferson and Lewis Counties.
When to Refer: Refer when an individual with a substance use disorder needs temporary, safe housing to support continued recovery while transitioning from treatment or the criminal justice system and awaiting permanent housing.
Citizen Advocates- Respite/Crisis Program
Services: Designed for adults in acute psychiatric distress, the Crisis Residence provides voluntary, 24/7 short‑term care in a safe and structured environment. Residents participate in therapy, skill‑building, emotional regulation activities, and daily routines that promote stabilization and support their transition back to everyday life.
Eligibility: Adults 18+ experiencing mental health crisis who need stabilization but do not require hospitalization. Must be voluntary and able to participate in crisis planning.
When to Refer: Client is in crisis but does not meet inpatient criteria, needs brief stabilization period, requires respite from current living situation, or as step-down from hospital to prevent readmission.
Health Home Care Management
Services: Health Home Serving Adults provides comprehensive care coordination for adults with serious mental illness (SMI) and/or chronic health conditions. Coordinates medical, behavioral health, educational, and social services. Offers care planning, health monitoring, provider coordination, and linkage to community resources.
Eligibility: Adults 18+ with serious mental illness (SMI) or 2+ chronic mental health and or physical health conditions (asthma, diabetes, obesity, etc.). Must be Medicaid eligible. Designed for adults with complex, co-occurring health and mental health needs.
When to Refer: Adult has SMI or 2+ chronic mental health and or physical health conditions, needs coordination across multiple medical and behavioral health providers, has complex medication regimen, struggles to manage multiple appointments and services, or individual requires integrated whole-person care management.
To access Health Home Care Management services, please complete the C-SPOA application or reach out to one of listed providers directly.
Care Management Agencies Serving Lewis County:
- ACR Health
- Bridging the Gap Care Management
- CHJC
- THRIVE Wellness and Recovery
THRIVE Wellness and Recovery – Adult Non-Medicaid Care Coordination
Services: Non-Medicaid Care Coordination provides comprehensive care coordination for adults with serious mental illness (SMI) and/or chronic health conditions. Coordinates medical, behavioral health, educational, and social services. Offers care planning, health monitoring, provider coordination, and linkage to community resources.
Eligibility: Adults 18+ who have one or more Serious Mental Illnesses (SMI) and are not eligible for Health Home Care Management Services (i.e., actively enrolled in Medicaid or Medicaid Managed Care). Individuals have significant behavioral, medical, or social risk factors which can be addressed through care management.
When to Refer: Adult has SMI and needs coordination across multiple medical and behavioral health providers, has complex medication regimen, struggles to manage multiple appointments and services, or individual requires integrated whole-person care management.
Lewis County AOT (Assisted Outpatient Treatment)
Services: Court-ordered treatment program for individuals who have difficulty engaging with voluntary services. Provides intensive case management, medication monitoring, therapy, and support services with legal oversight to ensure treatment compliance. Focuses on preventing relapse and hospitalization.
Eligibility: Adults 18+ with serious mental illness who meet AOT criteria: unlikely to survive safely in community without supervision, history of non-compliance with treatment leading to hospitalizations or incarceration, and unlikely to participate in treatment voluntarily. Requires court order.
When to Refer: Client has pattern of treatment non-compliance leading to repeated hospitalizations or involvement with criminal justice system, poses risk to self or others when not in treatment, or has been unsuccessful with voluntary services. Requires legal consultation for AOT petition.
Lewis County EVA (Enhanced Voluntary Agreement)
Services: Voluntary treatment program for individuals who have difficulty engaging with services. Provides intensive case management, medication monitoring, therapy, and support services ensure treatment compliance. Focuses on preventing relapse and hospitalization.
Eligibility: Adults 18+ with serious mental illness who meet EVA criteria: unlikely to survive safely in community without enhanced support, history of non-compliance with treatment leading to hospitalizations or incarceration, and willing to voluntarily engage.
When to Refer: Client has pattern of treatment non-compliance leading to repeated hospitalizations or involvement with criminal justice system, poses risk to self or others when not in treatment.