C-SPOA Service Providers & Referral Information
Health Home Serving Children
Services: Health Home Serving Children provides comprehensive care coordination for youth with serious emotional disturbance 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: Children and youth with serious emotional disturbance (SED) or 2+ chronic mental health and/or physical health conditions (asthma, diabetes, obesity, etc.). Must be Medicaid eligible. Designed for youth with complex, co-occurring health and mental health needs.
When to Refer: Youth with SED or 2+ chronic mental health and/or physical health conditions, needs coordination across multiple medical and behavioral health providers, has complex medication regimen, family struggles to manage multiple appointments and services, or child requires integrated whole-person care management.
To access Health Home Care Coordination services, please complete the C-SPOA application or reach out to one of listed providers directly.
Care Management Agencies Serving Lewis County:
- Bridging the Gap Care Management
- CHJC
- The Arc Jefferson – St. Lawrence
- The House of the Good Shepherd
- THRIVE Wellness and Recovery
THRIVE Wellness and Recovery – Children’s Non-Medicaid Care Coordination
Services: Non-Medicaid Care Coordination provides comprehensive care coordination for youth with one or more serious emotional disturbance (SED). Coordinates medical, behavioral health, educational, and social services. Offers care planning, health monitoring, provider coordination, and linkage to community resources.
Eligibility: Youth who have one or more serious emotional disturbance (SED) 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: Youth has SED 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.
Mobile Integration Team
Services: The North Country Mobile Integration Team (MIT) provides flexible, community‑based clinical support for youth with serious emotional disturbances. This multidisciplinary team offers mobile intervention, stabilization, skill‑building, peer support, and family engagement to help individuals remain safely in the community while progressing in their recovery. MIT partners closely with individuals and families, bringing services directly to them to support resilience, wellness, and long‑term stability.
Eligibility: MIT services are available to youth with serious emotional disturbances who need mobile, community‑based clinical support to maintain stability and safely remain in their home or community setting. Services are voluntary and designed for individuals who would benefit from flexible, intensive outreach rather than higher‑level or facility‑based care.
When to Refer: A referral to MIT is appropriate when a youth is struggling with significant mental health symptoms that are impacting daily functioning and require mobile, community‑based support to stay safe and stable in their environment. Refer when an individual needs flexible, team‑based intervention and ongoing engagement to prevent hospitalization, maintain community living, or support continued progress in recovery.
Home Based Crisis Intervention (HBCI)
Services: Home Based Crisis Intervention (HBCI) delivers intensive, family‑focused crisis intervention in the home for youth at imminent risk of psychiatric hospitalization. Over a brief 4–6‑week period, the program helps families stabilize crises, strengthen skills, and connect with community resources to support long‑term safety and stability.
Eligibility: HBCI services in Lewis County are available to youth ages 5–20 years and 11 months, who are experiencing a significant mental health crisis and are at imminent risk of psychiatric hospitalization.
This service is for children and adolescents who do not need immediate hospitalization.
When to Refer: Referrals to HBCI should be made when a child or adolescent is experiencing an acute mental health crisis and needs immediate, intensive support to avoid psychiatric hospitalization. Referrals may come from outpatient mental health providers, mobile crisis teams, the local Emergency Department, or any individual aware of the family’s need. Families may also self‑refer.
Children & Youth CCR (Community Residence)
Services: Children’s Community Residence provides 24-hour supervised residential treatment in a home-like community setting. Offers structured therapeutic environment with: individual and group therapy, psychiatric services, medication management, life skills training, educational support, family therapy, recreational activities, and discharge planning. Focus on stabilization and skill development for community reintegration.
Eligibility: Youth ages 5-21 with serious emotional disturbance who: cannot be safely maintained at home despite intensive community services, require 24-hour therapeutic structure and supervision, do not require hospital-level security, are able to participate in treatment and community activities, and have goal of returning to less restrictive community setting.
When to Refer: Youth cannot remain safely at home despite intensive services, requires 24-hour therapeutic milieu to stabilize, needs intensive skill-building in structured setting before returning home, is stepping down from hospital and needs transition support, or family needs time to prepare for youth’s return while youth receives intensive treatment.
OMH RTF (Residential Treatment Facility)
Services: Residential Treatment Facility provides the highest level of non-hospital residential mental health treatment. Offers highly structured 24-hour therapeutic environment with: intensive individual and group therapy, comprehensive psychiatric care, crisis intervention, medication management, behavioral programming, educational services, family therapy, and intensive discharge planning. Secure setting with high staff-to-youth ratio.
Eligibility: Youth ages 5-21 with serious emotional disturbance and: severe functional impairment requiring most intensive residential treatment, significant risk of harm to self or others, multiple failed placements at lower levels of care, complex psychiatric needs requiring intensive medical and therapeutic intervention, and cannot be safely treated in less restrictive setting.
When to Refer: Youth requires most intensive level of residential treatment, has failed at CCR or other residential settings, presents significant safety risk requiring secure therapeutic environment, has severe psychiatric symptoms requiring intensive intervention, or is stepping down from inpatient psychiatric hospitalization and needs extended stabilization before community return.
Citizen Advocates Crisis Residence
Services: The Youth Crisis Residence delivers short-term, 24‑hour therapeutic care for youth under 21 experiencing a mental health crisis. With structured daily routines, therapeutic groups, coping‑skills development, and family engagement, the program helps youth stabilize and return safely to their home and community.
Eligibility: Eligible youth are individuals under 21 who are in a mental health crisis and need short‑term stabilization in a supervised, therapeutic environment. Admission is voluntary and based on the need for 24‑hour support.
When to Refer: A referral is appropriate when a youth is in crisis and would benefit from temporary 24‑hour therapeutic care, increased supervision, and structured supports to help them regain stability and safely transition back home.
CHJC Therapeutic Crisis Respite Program (TCRP)
Services: The Therapeutic Crisis Residence Program delivers voluntary, short‑term crisis stabilization for youth ages 5–20. With 24‑hour supervision, individualized therapy, skill‑building, crisis planning, and strong family engagement, TCRP supports youth in building the skills and stability needed to return home safely with coordinated follow‑up care.
Eligibility: Eligible youth are individuals under 21 who are in a mental health crisis and need short‑term stabilization in a supervised, therapeutic environment. Admission is voluntary and based on the need for 24‑hour support.
When to Refer: A referral should be made when a youth is experiencing a mental health crisis that requires short‑term, 24‑hour supervision and stabilization in a voluntary residential setting but does not meet criteria for inpatient hospitalization.