Care Management


BFNC Care Management provides comprehensive services tailored to meet the unique needs of all individuals.

From the start each client is assigned a Care Manager. A BFNC Care Manager will work with you to understand what you need to stay healthy and live a balanced life. Your Needs May Require:

  • Housing
  • Food
  • Transportation Assistance for medical appointments
  • Medical Care Guidance to avoid Emergency Room Visits


A Care Manager ensures that everyone involved with an individual’s care is working together and sharing information that is important in the promotion of wellness.

A BFNC Care Manager will work with you to understand what you need to stay healthy and live a balanced life. You may need housing. You may need help getting enough food. You may need assistance in obtaining transportation to appointments.


  • Health Home Care Management provides free comprehensive care management services to Medicaid recipients to make certain their medical, mental health and substance use disorder needs are being met.
  • Assisted Outpatient Treatment Care Management Services (AOT)

    Erie County administers a program that provides Assisted Outpatient Treatment (AOT). This Program involves enhanced monitored comprehensive behavioral health services. Services are provided to individuals with a mental illness who, in view of their treatment history and present circumstances, are unlikely to survive safely in the community without supervision. The following questions and answers will help explain this new initiative and how to access Assisted Outpatient Treatment Services in Erie County.
    A person may be eligible to obtain AOT if he or she:

    • is at least 18 years of age and suffers from a mental illness; and
    • is unlikely to survive in the community without supervision, based on a clinical determination; and
    • has a history of non-compliance with treatment for mental illness which has led to either 2 hospitalizations for mental illness in the preceding 3 years, or resulted in at least 1 act of violence toward self or others, or threats of serious physical harm to self or others, within the preceding 4 years; and
    • is unlikely to accept the treatment recommended in the treatment plan; and
    • is in need of AOT to avoid a relapse or deterioration that would likely result in serious harm to self or others; and will likely benefit from AOT.

    Referrals for AOT ad CTI are made via the Erie County Department of Mental Health. To access the website and start the referral process, please click here

  • Non-Medicaid Care Management for Individuals 18 years and over living with a serious mental illness who do not have Medicaid. These referrals are received from Erie County Department of Mental Health.
  • Critical Time Intervention Services (CTI) for Individuals 18 years and over living with a serious mental illness.

    Critical Time Interventions (CTI) is an empirically supported, time-limited case management model designed to prevent relapse/ recidivism and other adverse outcomes in people with mental illness following discharge from hospitals, shelters, prisons and other institutions.
    CTI improves outcomes during vulnerable transition periods by:

    1. strengthening the individual’s long-term ties to services, family and friends, and
    2. by providing emotional and practical support during the critical time of transition.

    CTI workers establish a relationship with patients during their institutional stay. Post discharge work is organized in to (3) three phases:

    1. Transition: specialized support & implement transition plan – meet with caregivers, accompany client to providers, provide support, mediate conflicts
    2. Try Out: facilitate and test clients problem solving skills – observe support network, modify supports as needed
    3. Transfer of Care: terminate CTI services with support network safely in place – reaffirm roles of support network, develop and begin to set in motion long term goals, hold party/meetings to symbolize transfer of care.


Medicaid recipients 18 or older, living in Erie County, including those who are already members of a Managed Care Organization AND have Medicaid.


  • Two or more chronic health conditions such as: asthma, diabetes, heart disease, mental health, or a substance use disorder
  • OR Living with HIV/AIDS OR a significant mental illness