Care Coordination Agencies

Description: Programs that develop plans for the evaluation, treatment and/or care of individuals who, because of age, illness, disability or other difficulties, need assistance in planning and arranging for services; which assess the individual's needs; coordinate the delivery of needed services; ensure that services are obtained in accordance with the case plan; and follow up and monitor progress to ensure that services are having a beneficial impact on the individual. (AIRS PH-1000)

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Disclaimer...
Note: Service listings do not represent a recommendation or endorsement by the Medical Home Portal staff or its sponsoring organizations; nor do they reflect any assessment of the quality or value of a listed Service.

Statewide

Organization Name: Hasbro Children's Hospital
Address: 335R Prairie Avenue
RI 02905
Phone: 401-444-5685
Languages Spoken: Spanish
Services Provided: The Children's Neurodevelopment Center (CNDC) at Hasbro Children's Hospital provides evaluation and treatment of children with neurological, genetic, developmental, metabolic and behavioral disorders. The center incorporates multidisciplinary care with pediatric urology, orthopedics, neurosurgery and craniofacial programs.



The center is located on Prairie Avenue, in an area designed to be particularly spacious, comfortable and welcoming to children and their parents, who are essential partners in their children's care.
Provider Profiles: Clinics and Programs include

Genetics
Developmental and Behavioral Pediatrics
Psychological Services
Neurology
Spina Bifida Clinic
Neuromuscular Conditions Clinic
Metabolism and Nutrition Clinic
Pediatric Dermatology contact Gail Davis ext 40942
Pediatric Hematology/Oncology Contact Ann Rochette Ext 43760
Pediatric Asthma/Allergy/Immunology/Rheumatology (RIC) contact Margaret Prendergast ext 40949
Pediatric Endocrinology contact Margaret Prendergast ext 40949
Pediatric Nephrology contact Margaret Prendergast ext 40949
Pediatric Gastroenterology contact Kristina Travers ext 46734
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 4/12/2019
Organization Name: Community Care Alliance
Address: 245 Main Street
RI
Phone: 401-235-7000
Eligibility: Early Intervention serves eligible children from birth to three years of age and their families to promote the growth and development of infants and toddlers with developmental delays. Serving residents of Burrillville, Cumberland, Foster, Glocester, Johnson, Lincoln, North Providence, North Smithfield, Scituate, Smithfield and Woonsocket
Services Provided: Services are provided by a team of qualified professionals working in partnership with the family to ensure the best possible service provision.
Services include:
Comprehensive child & family assessment
Assistive technology services & referrals
Nutrition services
Occupational therapy
Physical therapy
Speech/language therapy
Child & parent group

Community Care Alliance Early Intervention program
245 Main Street
Woonsocket, RI 02895
Provider Profiles: A comprehensive community support agency that provides over 50 programs that range from home visiting and basic needs to substance abuse treatment. The other listing contains information on additional programs beyond Early Intervention. Intervention.
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 4/5/2017
Organization Name: Rhode Island Parent Information Network
Address: 1210 Pontiac Avenue
RI 02920
Phone: 401-270-0101
Toll Free Phone: 855-747-3224
Eligibility: Statewide
Services Provided: Rhode Island Parent Information Network (RIPIN) provides:
• Live answer call center during business hours, return calls within two business days
• Care coordination and service linkage for families with children with special health care needs
• Support for families navigating the special education process for children with special needs through our Parent Training and Information Center [http://www.parentcenterhub.org/]
• Support for families navigating transition to adult services for young adults with special needs
• Support for families with children with special health care needs through our Cedar Family Center

• Connection to Family Voices and Family-to-Family information and peer support groups [http://www.familyvoices.org/]
• Help with access to health care and health insurance including Healthsource RI, Medicaid, Medicare, and more
• Services provided in English and Spanish
Provider Profiles: Our mission is to assist individuals, parents, families, and children to achieve their goals for health, education, and socio-economic well-being by providing information, training, education, support and advocacy for person/family centered care and system change.

RIPIN’s staff are Certified Community Health Workers who have navigated health care and/or education systems for themselves or a loved one allowing for the inclusion of a peer perspective to our support to families.
Location:
RI Parent Information Network
1210 Pontiac Avenue
Cranston, RI 02920
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 7/3/2019

Cranston, RI

1210 Pontiac Avenue
Cranston, RI 02920
Phone: 401-270-0101
Organization Name: RI Parent Information Network
Address: 1210 Pontiac Avenue
Cranston, RI 02920
Phone: 401-270-0101
Languages Spoken: Spanish
Eligibility: Families of children birth to age 21 having 2 or more chronic conditions or have one chronic condition and are at risk of developing a second. Children having a severe mental illness or severe emotional disturbance Medical Assistance Coverage ( Medical Assistance, RIte Care or RIte Share)
Services Provided: A Cedar Family Center is a site that provides evolving, family centered, intensive care management and coordination in order to assist families in reaching their full potential and thrive in their own communities.
Provider Profiles: Our mission is to assist individuals, parents, families, and children to achieve their goals for health, education, and socio-economic well-being by providing information, training, education, support and advocacy for person/family centered care and system change.
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 12/14/2016

Middletown, RI

Organization Name: Child & Family of Newport
Address: 31 John Clark Road
Middletown, RI 02842
Phone: 401-849-2300
Eligibility: Residents of Barrington, Bristol,East Providence, Jamestown, Little Compton, Middletown, Newport, Portsmouth, Tiverton, Warren
Services Provided: Child and Family Counseling
Early Learning Center
Foster Care
Enhanced Outpatient Programs
Residential Programs
Substance Abuse Programs
East Bay's Family Care Community Partnership (FCCPs) agency, part of DCYF's network of prevention focused providers, brings community based services to children and families in order to build a stronger, brighter future. FCCP's focus on your family, and wrap you with the right local services and community programs to build a stronger family.
Provider Profiles: Child & Family is the largest and most comprehensive social service provider in Newport County, and one of the largest in the State of Rhode Island. It is a center for community involvement – a place where people come together to give help, to receive help and to support the work of others. With state-of-the-art Community Centers in both Middletown and Providence, Child & Family provides important services and programs to thousands of children, teens, families and elders throughout Rhode Island each year.
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 1/12/2018

Providence, RI

335 R Prairie Ave.
Suite 1A
Providence, RI 02905
Phone: 401-444-7703
Service Categories:
Organization Name: Lifespan
Address: 335 R Prairie Ave.
Suite 1A
Providence, RI 02905
Phone: 401-444-7703
Fax: 401-444-6115
Service Categories:
Eligibility: Must be eligible for Medical Assistance, including RIte Share and RIte Care under age 21, RI resident, live at home and meet the diagnostic criteria. Self-Referral or recommendation from Primary Care Physician, medical or behavioral specialist.
Services Provided: Care Coordination for families of children and youth with special needs. Cedar staff will work closely with the family and professionals to access needs and to develop a Shared Plan of Care .
We are a “one-stop shop” for your family, providing assessment, referrals and resources to help guide you during a difficult journey. At Three Cedar, we tailor an action plan to the goals you set for your child and family, and you’ll play a key role in making decisions about the plan.
Provider Profiles: Statewide
• Clinical Social Workers, MSW; Cedar experience +10 years
• Family Service Coordinators: Masters level/matriculated
Process:
• Bio-Psycho-Social Assessment of child and family
• Identify current issues and long term concerns
• Assess parent understanding and knowledge of child’s condition/disability/needs
• Intervention: Skilled clinician to help parent process impact of chronic conditions
• Care Plan Development with specified actions in collaboration with family
• Establish an individualized family safety/crisis plan as appropriate
• Provide ongoing care coordination
• Facilitate communication/collaboration with all providers
• Referrals to appropriate services
• Provide ongoing re-assessment for effectiveness and results of actions and referrals
• Assess for efficiency and avoidance of duplication
• Assess for successful goal attainment

Lifespan Cedar has Access to:
Developmental Pediatricians and other medical specialists at the Children's Neurodevelopment Center and within Lifespan
Psychology Services at the CNDC
(ACT clinic: ACT refers to Cedar and Cedar refers to ACT)
Value added: comprehensive Electronic Medical Records
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 1/12/2018

Warwick, RI

Address: 2733 Post Road
Warwick, RI 02886
Fax: 401-921-4918
Eligibility: accepts medicaid and a variety of insurances
Services Provided: Child Services include
Coordination of Care
Individual & Family Outpatient Counseling
​Social Skills Training
​Family Support and Training
Parent Coaching and Training
Home Based Therapeutic Services (HBTS)
Personal Assistance and Support Services ( PASS)
Adult Services include
Office-based counseling available for
Individuals, Families & Couples
Provider Profiles: The licensed clinicians and professional staff at Ocean State Behavioral provide an array of behaviorally based treatment and mental health services to children, families and adults. The agency mission is to provide quality behavioral, family centered, and strength based services to individuals and families. We are dedicated to empowering individuals to overcome challenges in order to achieve their goals.
Our main objective at OSB is to work with the family to assess the needs of the client and provide the services to address the identified needs. We believe that our role is not life-long. Our role is to teach the parents and children life-long support goals so that we are no longer needed. Empowering families to grow healthy in their own environment is one of our main focuses.
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 4/21/2016
Organization Name: Parent Support Network of RI
Address: 535 Centerville Road, Suite 202
Warwick, RI 02886
Phone: 401-467-6855
Toll Free Phone: 800-483-8844
Fax: 401-467-6903
Eligibility: Statewide
Services Provided: Workshops and Training's
Peer to Peer systems navigation support
Support Groups
Youth Group-Youth Speaking Out and Y.O.U.T.H. Move RI
Resource Center
Advocacy
Fatherhood Initiative and Support Group
Provider Profiles: Statewide: Parent Support Network of RI is an organization of families supporting families with children, youth and young adults who experience or at risk for serious behavioral health challenges.
We are a voice for the behavioral health of children, youth, siblings, and families. We believe we can and will make a difference through systems transformation so children and youth can live at home or in their community, receive effective services and supports that respect and consider their cultures and strengths, and respond to their individual and family needs.
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 6/27/2018

Woonsocket, RI

Address: Medical and Behavioral Health
450 Clinton Street
Woonsocket, RI 02895
Phone: 401-767-4100
Fax: 401-235-6896
Services Provided: Thundermist provides comprehensive health care services in order to meet the needs of each community. This includes:
Primary Medical Care, by board certified staff physicians who carry full hospital admitting privileges in our communities of service.
Dental Care by dentists and dental hygienists in our health centers.
QuickCare, Walk-in Medical Services located in each facility; open every day (and every holiday) with extended hours.
Behavioral Health Services in a fully integrated model alongside our medical services.
School-Based Health Care, including medical, dental, behavioral health and obesity management services.
Pharmacy, in partnership with CVS and Walgreens, providing discounted prescriptions to our patients.
WIC
Provider Profiles: Thundermist Health Center is a Federally Qualified Community Health Center, serving three communities -- Woonsocket, West Warwick, and South County .
Other location in Woonsocket for Dental and WIC
191 Social Street, 9th floor
Woonsocket, RI 02895
Dental 401- 767-4161
WIC- 401-767-4109
Original Source: Rhode Island Dept of Health, Office of Special Needs
Last Updated: 10/27/2017