Home & Community Based Services for Adults

About This Program

Goal-Oriented Care for Adults Navigating Mental Health Challenges

Overview

Designed for adults navigating mental health challenges, our home and community-based services offer personalized support that meets you where you are. Through intensive and short-term case management, peer services, and coordinated care, we help individuals build skills, access resources, and work toward recovery, stability, and a meaningful quality of life.

Intensive adult case management centers on transformative care for individuals with serious mental illness whose emotional or behavioral health significantly impairs their ability to function in daily life. These services focus not only on symptom management but also on empowering individuals to achieve meaningful and lasting change in their lives. Case management is rehabilitative and goal-oriented and includes service planning and coordination, treatment planning, monitoring progress, identification of change in clinical needs or level of treatment setting, and communication that is integral to continuity of treatment for the individual. Through personalized support, coordination of services, and ongoing therapeutic engagement, participants are guided in working toward recovery, resilience, and improved quality of life. Eligibility for these supports is based on a clinical assessment in accordance with DMH enrollment guidelines.

Services Available:

Residential
Psychiatry & Nursing
Outpatient Therapy
Group Support
Supportive Employment

These services are designed for adults experiencing impacts in their overall life functioning due to mental health concerns who need short term support. Participants have identified mental health needs and are engaged in a treatment process with clear, actionable goals. Individuals receive case management services focused on stabilizing key areas of life such as housing, employment, healthcare access, and community connection. Through a transformative care approach, the program emphasizes person-centered planning, empowerment, and skill-building to support recovery, improve functioning, and enhance overall well-being.

Peer Services are delivered in alignment with Vermont’s Peer Services initiative and the evidence-based model of Intentional Peer Support (IPS), offering connection, hope, and mutual learning. This approach complements clinical and case management services by fostering empowerment, trust, and a sense of shared understanding, supporting individuals in reaching their wellness goals through authentic, person-centered relationships.

COORDINATED CARE FOR VETERANS & MILITARY FAMILIES

We provide specialized care coordination services designed to support veterans, active-duty service members, and their families in accessing the full spectrum of health and social services they need. Our approach ensures timely, connected, and personcentered care, integrating mental health, substance use treatment, primary care, and community-based supports into a seamless system of care.

PROACTIVE ENGAGEMENT & ONGOING SUPPORT

We actively work to keep veterans connected to care by:

Conducting outreach and home visits
Following up after missed appointments
Supporting engagement across the continuum of care
Helping individuals overcome barriers such as tranportation, stigma, and system complexity

A SINGLE POINT OF COORDINATION ACROSS SYSTEMS

Navigating healthcare and support systems can be
complex. Our Care Coordinators serve as a central
point of contact, helping individuals access and
connect services across:

VA healthcare systems and Vet Centers
Community behavioral health providers
Hospitals and emergency departments
Housing, benefits, and social service programs\

NAVIGATION OF VA BENEFITS AND COMMUNITY RESOURCES

Our Care Coordinators support with navigating complex systems, including:

VA healthcare enrollment and coordination
Disability claims and benefits
TRICARE and insurance navigation
Access to housing and supportive services

Our goal is to help veterans receive the full range of benefits and supports available to them.