Care Coordination

Callen-Lorde has various Care Coordination services that will suit any patient’s needs. For patients receiving medical care at Callen-Lorde, our Care Coordination department offers assistance with obtaining benefits and entitlements, HASA, ADAP, insurance navigation, gender marker changes, surgery coordination, and escorts to outside health care services. We can also provide referrals for housing, financial assistance, intimate partner violence, legal assistance, and other public and private resources.

Care Coordination services include:

Supportive Care Coordination

The Supportive Care Coordination program is open to all active Callen-Lorde patients. Patients accessing Supportive Care Coordination meet with a Case Manager for a brief visit to be connected to various benefit programs, community resources, culturally competent medical and mental health referrals (including gender affirming surgeons), housing resources, and legal services. Case Managers also help patients navigate health insurance issues. A detailed list of services is below.

Patients can come to a case management walk-in session, located on the 6th floor of Callen-Lorde’s main Chelsea location. Walk-in sessions are limited to 30 minutes and are first come, first served. Walk-in hours are as follows: Mondays through Thursdays 9:00am – 6:30pm; Fridays 9:45am – 3:30pm. Hours are subject to change due to staffing or holidays so please call (212) 271-7200 for updates. Patients may also call the Supportive Care Coordination number: (212) 271-7202 to leave a detailed voicemail and a Supportive Case Manager will return the call as soon as possible.

Supportive Care Coordination Case Managers can refer patients to:

  • Food Assistance: Click this link to locate a food pantry or soup kitchen near you.
  • Housing resources: Please note that Callen-Lorde is not a housing agency. Case Managers can provide patients with a list of housing resources in the community. * HASA: Click this link to determine if you are eligible for HASA services before meeting with a Case Manager.
  • Chest / Breast exams: Note that you do not have to be insured to have a chest / breast exam! A Case Manager can enroll you into financial assistance programs to help you cover the cost of your chest / breast exam.

Supportive Care Coordination Case Managers help patients with:

  • Correcting gender markers: Please note that you will need a letter from your Callen-Lorde primary care provider to correct your gender marker. These letters can take up to 4 weeks to be generated. * Name change: Click this link for a step-by-step guide on how to change your name. If you have questions after reading the name change guide, please come see a Case Manager. If you have legal questions about the name change process, we recommend that you reach out to either the Transgender Legal Defense & Education Fund or the Sylvia Rivera Law Project.
  • Gender affirming surgery coordination: Please note that this type of session can take longer than 30 minutes, so we strongly recommend scheduling a case management appointment instead of a walk-in to begin this process. Based on the surgeon you choose to work with and your insurance plan guidelines, you may need letters of support from your primary care provider, a mental health therapist, and/or a psychiatrist. We can help you navigate this process.
  • Food stamp (SNAP) benefits and/or other entitlement programs

Insurance help:

  • Enrollment in ADAP and APIC: We can assist you in enrolling for these programs. You can call the ADAP / APIC programs directly with any questions at 1-800-542-2437. The fax number for ADAP / APIC is 518-459-2749.
  • Enrollment in medication co-payment assistance programs
  • Insurance help:
    • Enrollment in ADAP and APIC: We can assist you in enrolling for these programs. You can call the ADAP / APIC programs directly with any questions at 1-800-542-2437. The fax number for ADAP / APIC is 518-459-2749.
    • Enrollment in medication co-payment assistance programs

SCC Walk in hours are available Monday – Thursday, 9:00am – 6:30pm and Fridays from 9:45am – 3:30pm

Intensive Care Coordination

We get that it can be difficult to manage all of the different pieces of the current healthcare and social services setting. Managing your insurance, pharmacies, housing, cash assistance or other social benefit programs have all become overly complicated and difficult to navigate without additional support. Intensive HIV Care Coordination is a program where you can receive care coordination services both within the clinic and in your community or home around issues of treatment/illness education, treatment adherence, and social benefit services. Once enrolled in this program you are connected with both a Care Coordinator and a Patient Navigator and are provided with appointment reminders and escorts, advocacy at various social service agencies, health promotion to support better understanding of your health, adherence support to offer friendly reminders of medications, and assistance with keeping all of your providers informed of your needs. As part of participating in this program you will also be eligible to obtain transportation assistance for any appointments related to your care management needs.

Legal Services

Manhattan and South Brooklyn Legal Services have partnered with Callen-Lorde Community Health Center to provide you with legal support to ensure equal access to justice for the people of New York City by providing free counsel and legal advice to those who may otherwise be unable to afford it. Legal Services can assist you in legal support for issues involving housing, benefits (SSD/SSDI), family law, discrimination, confidentiality, advance directive/will issues, and other civil legal matters/

Our Medical-Legal Partnership offers weekly scheduled onsite legal intake appointments at our 17th street location (230 West 17th St) every Wednesday evening from 5pm-8pm. There is also the option of walking in for a stand-by intake appointment at 5pm on Wednesday’s to be seen at the first opportunity. We can guarantee two walk-ins will be fit into the schedule on a first come first serve basis, please be prepared for possible wait times. Please arrive as close to 5pm as possible to secure a spot for the evening.

Health Homes

Health Homes is a Care Coordination program for Medicaid recipients, aimed to help you increase your access to primary and specialty care. Health Homes operates from an integrated health care model, removing barriers between you and your medical, behavioral, and social support needs. A Health Home Patient Navigator can help eliminate some of the confusion around complex medical and social needs by offering appointment reminders, accompaniment to doctor visits, and helping to bridge the gap between various areas of care. They can also work with you on coordinating entitlement benefits, food, housing, and legal services. Patients who are already engaged in mental health treatment can work with a Patient Navigator who is skilled in the area of mental health care management. All of our Patient Navigators are compassionate, sensitive, and patient-centered, meaning they will work with you on an individual care plan to address your goals. In order to qualify, you must be Medicaid eligible and meet the following criteria:

  • Severe Mental Illness or HIV/AIDS

OR

  • Two or more chronic conditions (including but not limited to; Mental Health Conditions, Substance Use Disorder, Asthma, Diabetes, Hypertension, Chronic Pain)

If you are interested in the program, please speak with your medical or mental health provider for a referral.