ADULT CARE COORDINATION
Adult Community and Homelessness Support
Adult Care Coordination provides a variety of community-based services such as case management, homeless assistance, supervised housing, and intensive outpatient community assistance.
Assertive Community Treatment
Assertive Community Treatment, or ACT is a team of medical, behavioral health, and rehabilitative professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. Admission criteria include severe and persistent mental illness, predominately Schizophrenia, and high service needs in order to maintain stability.
ACT consists of the following services: service coordination, psychiatric assessment and treatment, medication management, substance use services, counseling/therapy, vocational services, mental health support services, peer support, and representative payee services. ACT services are flexible and teams offer personalized levels of care for all individuals, adjusting service levels to reflect needs as they change over time.
The goal of ACT is to lessen or eliminate debilitating symptoms of mental illness each client experiences and to minimize or prevent recurrent episodes of illness, assist clients to meet basic needs and enhance their quality of life, improve functioning in adult social and employment roles and activities, increase stability in community, decrease hospitalizations, and lessen the family's burden of providing care.
Community served: Adults 18 and older
Contact us: 757-788-0473
This program operates 24 hours a day, 7 days a week.
State Hospital Discharge Planning
The State Hospital Discharge Planning team provides case management and discharge planning services to individuals admitted to State psychiatric facilities. The team, comprises Discharge Planners and Case Managers, advocates for individual needs, monitors individuals’ progress with treatment goals, and coordinates optimal transition to the community.
The staff serves individuals with serious mental illnesses, intellectual or developmental disabilities, and/or individuals with substance use concerns. Staff also work with individuals on Not Guilty by Reason of Insanity status (NGRI) and closely monitor their progress throughout admission to the hospital. Staff, including the NGRI Coordinator, collaborate with the legal system and mental health providers to develop appropriate discharge plans to assist with individuals’ recovery and reintegration to the community.
The H-NNCSB State Discharge Planning Team is routinely viewed as one of the best in the State. Staff are compassionate towards individual needs and knowledgeable of community resources.
Community served: Adults 18 and older
Contact us: 757-788-0083
Monday - Friday 8:30 am - 5:00 pm
Reinvestment Case Management
Reinvestment Discharge Planning and Case Management is a function of the Regional Reinvestment Project, which was developed to reduce the usage of inpatient beds at state psychiatric facilities and to develop community supports.
The staff monitor inpatient treatment, develop discharge plans and provide linkage to community resources upon discharge. The cases are managed short-term, usually less than ninety days, and are linked to the larger CSB service delivery system.
Community served: Adults 18 and older
Contact us: 757-788-0083
Monday - Friday 8:00 am - 5:00 pm
Adult Mental Health Case Management
The Hampton-Newport News Community Services Board Case Management services enable individuals with a Serious Mental Illness, or Serious Mental Illness and Co-occurring Substance Use Disorders, to achieve and maintain optimal functioning in the least restrictive, most normative community setting. We achieve our mission by assessing individuals’ needs and strengths, linking them with community services and supports, and monitoring their response to treatment and the quality of care provided.
All Case Management services are focused on individual needs and are carefully crafted to be sensitive to cultural values and preferences. Individuals typically served by Case Management have complex behavioral health needs requiring multiple services and supports.
Community served: Adults 18 and older
Contact us: 757-788-0053
Monday - Friday 8:00 am - 5:00 pm
Homeless Services
Project for Assistance in Transition from Homelessness (PATH)
PATH provides services to individuals who are homeless or at imminent risk of becoming homeless and who suffer from serious mental illness (SMI) or SMI and co-occurring substance use disorders (SUD). Often these individuals have experienced chronic homelessness and untreated mental illness/substance abuse for many years and are not engaged in services.
PATH provides services and supports to outreach, identify and engage persons into services with the end goal of transitioning from homelessness or risk of homelessness into behavioral health, social services and housing in order to promote recovery and self-determination. Outreach results in increased access to and utilization of community services by individuals served.
Community served: Adults 18 and older
Contact us: 757-240-5288
Monday - Friday 8:00 am - 5:00 pm
Homeless Services
Newport News PORT Outreach
NN PORT Outreach provides services to persons who are homeless or at imminent risk of becoming homeless and who suffer from serious mental illness (SMI) or SMI and co-occurring substance use disorders (SUD). Often these individuals have experienced chronic homelessness and untreated mental illness/substance abuse for many years and are not engaged in services.
NN PORT Outreach provides services and supports to the target population to outreach, identify and engage such persons into services with the end goal of transitioning from homelessness or risk of homelessness into behavioral health, social services and housing in order to promote recovery and self-determination.
Community outreach is provided to the cities of Hampton and Newport News and includes other service sites for homeless individuals such as shelters, day centers, and soup kitchens. Outreach extends to client campsites and vacant houses and street sites. Outreach workers provide linkage to basic needs such as food, shelter and clothing and linkage to ongoing services. Assistance through outreach services is about six months to a year.
Contact us: 757-240-5288
Monday - Friday 8:00 am - 5:00 pm
Homeless Services
Safe Harbors
Safe Harbors Program is intended to reduce homelessness by providing housing first. It is also intended to maximize consumers’ opportunities and independence by providing quality supports, training and individualized services to individuals who are homeless who suffer from serious mental illness (SMI) or SMI and co-occurring substance use disorders (SUD). Individuals served must be a single adult who has been homeless for the past year or experienced numerous episodes of homelessness over the year and are not currently engaged in any treatment or community services. Documentation of homelessness is required.
The Safe Harbors Permanent Supportive Housing Program provides housing in local apartments, while supporting individuals with developing the skill necessary to manage their independence. Services are individualized based on each consumer’s goals, needs, and desires. The individuals are monitored weekly for progress with linkage and engagement into community services, resources and treatment. The goal is to move individuals into independent housing in the community that fits the client's needs and reduces the risk of additional episodes of homelessness. There is no time frame on how long a client can stay in the program.
Community served: Adults 18 and older
Contact us: 757-240-5288
Monday - Friday 8:00 am - 5:00 pm
Service Coordination Team
The Service Coordination Team provides crisis support services to individuals who could benefit from more intensive outpatient services in the community. The team provides on-going monitoring of safety, coping skills education, recovery tools, and linkages to CSB and community resources. One of the team’s goals is to assist individuals with maintaining stabilization in the community upon discharge from a psychiatric facility.
This team assists individuals enrolled in the CSB system and is an excellent support to the Reinvestment Case Management Team, Emergency Services and other CSB programs. The team utilizes Case Management and Peer Support Staff. The Peer Support Specialist is a vital component to the team– sharing real life recovery experiences which benefit the individuals served on their recovery journey.
Community served: Adults 18 and older
Contact us: 757-788-0083
Monday - Friday 8:00 am - 5:00 pm
Transcend Place
The mission of the MH Regional Supervised Housing Program is to reduce the length of stay in local and state psychiatric facilities by providing a living environment that will maximize the individual’s opportunities and independence by providing quality supports, training and individualized services to individuals with severe mental illness and possible co–occurring substance use disorder. The MH Regional Supervised Housing Program supports individuals in their personal choices and works closely with them to engage them in services to maximize their independence and reduce hospital admissions.
Length of stay in the MH Regional Supervised Housing Program is dependent upon the individual’s goals, needs, and desires. Staff work closely with the individual to engage them in treatment such as psychiatric, substance use, medical and any other treatment the individual may need. Staff also assist with applications for financial and medical benefits and with obtaining a day activity such as psychosocial program participation, partial hospitalization, vocational programs, volunteer opportunities or employment.
Individuals from Region V who are on the discharge ready list at Eastern State Hospital or ready for discharge whose needs could be met in a community setting have priority consideration for this services.Community served: Adults 18 or older, resident of Hampton Roads/Tidewater area, must have a psychiatric diagnosis determining need.
Contact us: 757-596-4926
This program operates 24 hours a day, 7 days a week.
Interested in some general information about Adult Care Coordination?
We want to know your needs exactly so that we can provide the care you need. If you are not sure about which program is best for you, call us at the main number for our ACC programs.