Western New York
Social Care Network
Integrated Care
Better Health with Integrated Care.
Serving Cattaraugus, Chautauqua, Erie, and Niagara Counties
Individual Seeking Services for Yourself or Family
Submit a Referral for an Individual
Organizations Interested in Joining Our Network
Services Available
Services available to eligible participants and subject to availability.
Housing and Utilities Support
- Modifications like ramps, handrails, and grab bars to make your home accessible and safe
- Repairs to fixing water leaks to prevent mold growth
- Sealing holes and cracks to prevent pests from entering
- Modifications to air conditioner, heater, humidifier, or dehumidifier to improve ventilation
- Assistance with applications for safe and stable housing in the community
Nutrition and Food Supports
- Registered Dietitian services and group nutrition classes to support you in choosing healthy foods to meet your needs and goals
- Prepared meals, fresh produce, or grocery items – tailored to your specific health needs
- Cooking supplies like pots, pans, small appliances and utensils to prepare meals
Transportation
- Public or private transportation to non-medical places such as: job interviews, parenting classes, housing court to prevent eviction, local farmers’ markets, and city and state department offices to obtain important documents
Care Management
- Helping you find a job or training program, apply for public benefits, manage your finances, and more.
- Connecting you to services like childcare, counseling, crisis intervention, health homes program, and more.
What is the Integrated Care Social Network?
A thriving community goes beyond healthcare. At Integrated Care we are committed to helping our neighbors achieve Better Health through Integrated Care.
The Integrated Care Social Care Network links individuals and families with essential resources that address the social factors impacting health, such as housing, employment, food, and transportation.
Integrated Care is a regional initiative that unites community-based organizations with health centers and behavioral health providers to form a coordinated system aimed at addressing the underlying causes of health inequities. By integrating social supports with health services we work to enhance the overall well-being of Medicaid recipients across Western NY.
Individual Seeking Services
STEP 1: GET SCREENED. Before you can be referred for services, we need to better understand what your needs are and if you are eligible for services under this Program. To do so, we have to ask you a few questions about housing and utilities, food security, transportation, employment, education, and interpersonal safety. Screenings are only done with your consent and the information you give is only used to determine your needs and eligibility.
OPTION 1: CONTACT US: To contact the Integrated Care Social Care Network to learn more about services available to individuals with NY Medicaid health insurance – CLICK HERE or Call us: 716-431-5100 extension 1
OPTION 2: COMPLETE A SELF-SCREEN: To submit a self-screen regarding your health-related social care needs to help determine if you (or your child/ dependent) are eligible for services – please CLICK HERE** .** This information will be shared with Integrated Care and a Navigator will reach out to you to discuss your answers and eligibility.
OPTION 3: In-Person Screening Available at the following Social Care Network Partner locations:
Network Partners
| Name | Counties where Services Are Provided | Services offered in the following Languages: | Address | Hours of Operation | Phone Number | Website link (Link the Org Name to the websie) |
|---|---|---|---|---|---|---|
| Buffalo Prenatal-Perinatal Network Inc | Erie | English, Spanish | 703 Washington Street Buffalo, NY 14203 | 9am-5pm Monday - Friday | 716-884-6711 ext. 1007 | https://www.bppn.org/ |
| Create a Healthier Niagara Falls Collaborative, Inc. | Niagara | English | 9860 Niagara Falls Boulevard PO Box 193 Niagara Falls, NY 14304 | 9am-5pm Monday - Friday | 716-777-1034 | https://www.healthierniagarafalls.org/ |
| Creative Restorations INC | Cattaraugus, Chautauqua, Erie, Niagara | English | 371 Delaware Avenue Buffalo, NY 14202 | 9am-5pm Monday - Friday | 716-553-4886 | https://creativerestorationsinc.org/ |
| Faith Based Fellowship | Erie | English | 722 Willam Street Buffalo, NY 14202 | 9am-5pm Monday - Friday | 716-536-8360 | |
| Family Service of the Chautauqua Region, Inc. | Chautauqua | English | 332 E 4th Street Jamestown, NY 14701 | 9am-5pm Monday - Thursday, 8am-4pm Fridays | 716-488-1971 | https://fscrmentalhealth.com/ |
| Jewish Family Service of Buffalo and Erie County | Erie and Niagara | English, Spanish, Arabic | 70 Barker Street Buffalo, NY 14209 | 8am-5pm Monday-Thursday; 8am-2pm Fridays | 716-883-1914 | https://jfswny.org/ |
| LifeSource Systems Inc. | Cattaraugus, Chautauqua, Erie, Niagara | English | 163 Richmond Avenue Buffalo, NY 14222 | 9am-5pm Monday - Friday | 716-249-1019 | https://lssiny.org/ |
| Mental Health Association of Erie County Foundation INC | Cattaraugus, Chautauqua, Erie, Niagara | English | 1021 Broadway Street 5th Floor Buffalo, NY 14212 | 9am-4pm Monday - Friday | 716-886-1242 | https://mhawny.org/ |
| Prevention Works, INC. | Chautauqua | English | 1 E Main Street Falconer, NY 14733 | 8:30am-4:30pm Monday - Friday | 716-664-3608 ext. 100 | https://preventionworks.us/ |
| South Buffalo Community Association INC | Cattaraugus, Chautauqua, Erie, Niagara | English | 35 Cazenovia Street Buffalo, NY 14220 | 8:30am-3:30pm Monday - Friday | 716-822-4532 | https://www.southbuffalo.org/ |
| WNY Mobile Overdose Prevention Services | Erie and Niagara | English, Spanish | 800 Sycamore Street Buffalo, NY 14212 | 9am-5pm Monday - Friday | 716-256-5221 | https://www.wnymobileops.com/ |
| Southern Tier Health Care System Inc | Cattaraugus and Chautauqua | English | 150 N Union Street Olean, NY 14760 | 9am-5pm Monday - Friday | 716-372-0614 | https://www.sthcs.org/ |
| New Directions Youth and Family Services Inc | Cattaraugus, Chautauqua, Erie, Niagara | English | 4511 Harlem Road Amherst, NY 14226 | 9am-5pm Monday - Friday | 716-334-3285 | https://www.fosteringgood.org/ |
| Gerard Place | Erie, Niagara | English, Arabic, Bengali | 2515 Bailey ave Buffalo, NY 14215 | 8:30am-5pm Monday - Friday | 716-897-9948 | https://gerardplace.org/ |
| Harvest House | Erie, Niagara | English, Spanish, French | 175 Jefferson ave Buffalo, NY 14210 | 8am-4pm Monday - Friday | 716-855-0654 | https://www.harvesthousebuffalo.org/ |
| Health Community Alliance | Cattauragus, Chautauqua, Erie | 1 School st suite 100 Gawanda, NY 14070 | 8am-4:30pm Monday - Friday | 716-532-1010 | https://www.communityalliance.org/ | |
| Jewish Community Center | Cattaraugus, Chautauqua, Erie, Niagara | English | 2640 North Forest Road Getzville, NY 14068 | 5:30am-9pm Monday - Thursday 5:30am-8pm 8am-6pm Saturday-Sunday | 716-688-4033 | https://www.jccbuffalo.org/ |
| Family Help Center | Erie, Niagara | 60 Dingens st Buffalo, NY 14206 | 8:30am-5pm Monday - Friday | 716-822-0919 | https://familyhelpcenter.net/ | |
| Westside Community Services | Erie | 161 Vermont st. Buffalo, NY 14213 | 9:30am-6pm Monday- Friday | 716-884-6616 | https://wscsbuffalo.org/ | |
| Chatauqua Opportunities | Chautauqua | 17 W. Courtney St. Dunkirk, NY 14048 | 8:30am-4:30pm Monday - Friday | 716-366-3333 | ||
| Niagara Falls Memorial Medical Center | Niagara | English, Spanish, Arabic | 621 Tenth st. Niagra Falls, NY 14302 | 8am-5pm Monday-Friday | 716-278-4000 | https://nfmmc.org/ |
| Buffalo Urban League Inc | Chautauqua, Cattauraugus, Erie, Niagara | English, Spanish, Chinese - Mandarin, Other | 15 Genesee Street Buffalo, NY 14203 | 8am-5pm Monday- Friday | 716-250-2400 | https://www.bulny.org/ |
STEP 2: Based on your Needs and your Eligibility, you may be eligible for a referral for additional Enhanced Services such as Nutrition Counseling, Food Services, Housing Supports and non-medical Transportation.
Your Social Care Navigator will work with you to coordinate any Enhanced Services you are eligible to receive. We are adding new partners to provide the Enhanced Services weekly.
Additional Network Partners Providing Enhanced Services
| Name | Services | Languages | Address | Hours | Phone | Website |
|---|---|---|---|---|---|---|
| RxDiet | Medically Tailored Meals, Clinically Appropriate Meals, Food Prescriptions Cattaraugus, Chautauqua, Erie, Niagara | English, Spanish | 9am-5pm Monday - Friday | https://www.rx-diet.com/ | ||
| Belmont Housing | Pre-Tenancy - Housing, Tenancy Sustaining - Housing, Housing Navigation, Rent/ Temporary Assistance, Community Transitions Service | English, Spanish | 2393 Main st. Buffalo, NY 14209 | 9am-5pm Monday- Friday | 716-884-2538 | https://www.belmonthousingwny.org/services/ |
| Epicured | Medically Tailored Meals, Clinically Appropriate Meals, Food Prescriptions, Nutrition Counseling Cattaraugus, Chautauqua, Niagara, Erie | English | 516-642-7315 | https://www.epicuredinc.com/ | ||
| Catholic Charities | Cooking supplies, Asthma Self- Management, Pre- Tenancy, Tenancy Sustaining (coming very soon), Housing Navigation/ Transition (coming very soon), Rent/ Temporary Assistance (coming very soon), Community Transitions (coming very soon) | English | 741 Delaware ave Buffalo, NY 14209 | 8am-5pm Monday- Friday | 716-218-1400 | https://ccwny.org/ |
| Community Actions of Niagara Frontier Inc. | Food Prescriptions, Pantry Stocking, Pre-Tenancy, Tenancy Sustaining, Housing Navigation / Transition, Community Transitions, Rent/ Temporary Assistance Transportation | 1570 Buffalo Ave. Niagara Falls, NY 14303 | 24 hours | 716-285-3403 | https://www.communitymissions.org/ | |
| Niagara Falls Memorial Medical Center | Screening, Navigation | English, Spanish, Arabic | 621 Tenth St. Niagara Falls, NY 14302 | 8am-5pm Monday- Friday | (716) 278-4000 | https://nfmmc.org/ |
| Buffalo Federation of Neighborhood Centers | Pre-Tenancy, Tenancy Sustaining, Housing Navigation /Transition, Pantry Stocking, Rent/Temporary Assistance, Utilities, Community Transitions, Transportation (coming soon) | English, Spanish | 2365 Main St. Buffalo, NY 14214 | 8am-5pm Monday- Friday | 716-852-5065 | https://bfnc.org/ |
| Community Nutrition Paternship (Freshflavor RX) | Nutition Counseling, Medically Tailored/ Clinc. Approved Meals, Food Prescriptions, Pantry Stocking | English | 8am-5pm Monday- Friday | (716) 961-2590 | https://cnpwny.org/ | |
| Parent Network Of Western New York | Screening, Navigation, Cooking Supplies | English, Spanish | 1021 Broadway St. Buffalo, NY 14212 | 9am-5pm Monday- Friday | 716-332-4170 | https://parentnetworkwny.org/ |
| God's Love We Deliver | Cooking supplies, Medically Tailored/ Clinic. Approved Meals, Food Prescriptions | English, Spanish, Chinese - Mandarin, Chinese - Cantonese | 9am-5pm Monday- Friday | 212-294-8100 | https://www.glwd.org/ | |
| Homespace Corp. | Screening navigation, cooking supplies, nutrition counseling, pantry stocking, Pre-Tenancy, Tenancy Sustaining, Housing Navigation /Transition, Rent/Temporary Assistance, Utilities, Community Transitions | English | 1030 Ellicott St. Buffalo, NY 14209 | 9am-5pm Monday- Friday | 716-881-4600 | https://www.homespacecorp.org/ |
| Journey's End | Screening navigation, cooking supplies: (coming soon), Pre-Tenancy: (coming soon), Tenancy Sustaining: (coming soon), Housing Navigation /Transition: (coming soon), Rent/Temporary Assistance: (coming soon), Utilities: (coming soon), Community Transition: (coming soon), Transportation: (coming soon) | English | 2495 Main St. Buffalo, NY 14214 | 8am-5pm Monday- Friday | (716) 882-4963 | https://www.jersbuffalo.org/ |
| YWCA Jamestown | Pre-Tenancy, Tenancy Sustaining, Housing Navigation /Transition, Rent/Temporary Assistance, Utilities, Community Transitions | English | 401 North Main St. Jamestown, NY 14701 | 8am-5pm Monday- Friday | 716-488-2237 | https://www.ywcajamestown.com/ |
| Mercy Home Care | Screening Navigation (coming soon), Cooking Supplies (coming soon) | English, Spanish | 8:30am-4:30pm Monday - Friday | (716) 819-5300 | https://www.chsbuffalo.org/ | |
| Peaceprints | Screening Navigation, Cooking Supplies, Nutrition counseling | English | 1001 E. Delavan Ave. Buffalo, NY 14215 | 8am-5pm Monday- Friday | 716-856-6131 | https://www.peaceprintswny.org/ |
| The Resource Center | Pre-Tenancy, Tenancy Sustaining, Housing Navigation /Transition, Pantry Stocking, Rent/Temporary Assistance, Utilities, Community Transitions | English | 200 Dunham Ave. Jamestown, NY 14701 | 8am-5pm Monday- Friday | 716-483-2344 | https://resourcecenter.org/ |
| Rural Outreach Center | Screening Navigation, Cooking supplies, Pre-Tenancy, Tenancy Sustaining, Housing Navigation /Transition, Pantry Stocking, Rent/Temporary Assistance, Utilities, Community Transitions | English | 730 Olean Rd. East Aurora, NY 14052 | 8am-5pm Monday- Friday | 716.240.2220 | https://theroc.co/ |
| St. Luke's Episcopal Church | Food Prescription, Pantry Stocking | English | 410 N. Main St, Jamestown, NY 14701 | 9am-5pm Monday- Friday | 716-483-6405 | https://jfmny.org/ |
| Horizonal Health Services | Screening Navigation | English | 291 Elm St. Buffalo, NY 14201 | 8am-4pm Monday - Friday | 716-831-1800 | https://horizon-health.org/ |
| Asian Pacific Islander American Public Affairs Association | Screening Navigation, Cooking supplies | English, Chinese Mandarin | 4:45pm-6pm Monday | https://www.apapa.org/ | ||
| Baker Hall DBA OLV Human Services | Screening Navigation, Housing Navigation /Transition, Cooking supplies, Pantry Stocking | English | 8am-5pm Monday- Friday | 716-828-9500 | https://www.olvhs.org/ | |
| Cazenovia Recovery | Screening Navigation, Housing Navigation /Transition, Cooking supplies | English | 4295 Main St. Buffalo, NY 14214 | 8am-5pm Monday- Friday | 716-852-4331 | https://cazanoviarecovery.org/ |
| Chautauqua County Rural Health Ministry | Screening Navigation, Food Prescription, Cooking supplies, Pantry Stocking | English | 319 Washington Ave. Dunkirk, NY 14048 | 8am-4pm Monday - Friday | 716-366-1787 | https://theccrm.org/ |
| Family Promise of Western New York | Screening Navigation, Housing Navigation /Transition, Cooking supplies | English, Spanish | 75 Hickory St. Buffalo, NY | 9am-5pm Monday- Friday | 716-771-3007 | https://fpwny.org/ |
| Harmonia | Screening Navigation,Cooking supplies, Nutrition Counseling | English | 97 S. Buffalo St. Hamburg, NY 14075 | 8am-5pm Monday- Friday | 716-947-5025 | https://www.harmonia-care.org/ |
| Jericho Road Community Health Center (2A) | Cooking supplies | Arabic, Bengali, Burmese, English, Swahili | 182 Breckenridge St. Buffalo, NY 14213 | 8am-5pm Monday- Thursday 9am-4pm Friday | 716-348-3011 | https://jrchc.org/ |
| Mercy Home Care | Screening Navigation,Cooking supplies | Arabic, Bengali, English, Punjabi, Spanish, Swahili | 8:30am-4:30pm Monday - Friday | 716-923-9674 | https://www.chsbuffalo.org/ | |
| Oishei Children’s Hospital (2A w/CF) | Screening Navigation,Cooking supplies | American Sign Language, Arabic, Bengali, Chinese Mandarin, English, French, Spanish | 818 Ellicott St. Buffalo, NY 14203 | 8am-5pm Monday- Friday | 716-370-1000 | https://www.ochbuffalo.org//?utm_source=extnet&utm_medium=yext |
| Positive Direction Foundation Inc. | Screening Navigation,Cooking supplies | English | 50 Fountain Plaza Suite 1400 Buffalo, NY 14202 | 9am-5pm Monday- Friday | 716-704-5510 | https://www.pdawny.com/ |
| Ronald McDonald House of Rochester | Screening Navigation, Cooking supplies | English | 333 Westmoreland Dr. Rochester, NY 14620 | 8am-5pm Monday- Friday | 585-442-5437 | https://rmhcrochester.org/ |
| Salvation Army Buffalo | Screening Navigation, Housing Navigation /Transition, Pantry Stocking, Nutrition Counseling, Cooking supplies | English | 960 Main St. Buffalo, NY 14202 | 8am-5pm Monday- Friday | 716-883-9800 | https://easternusa.salvationarmy.org/empire/buffalo/ |
Submit a Referral
To submit a referral to Integrated Care for an individual click here. The individual will be contacted by a Navigator to provide more information and begin screening and process to determine eligibility for services.
Learn About Our Network
Please click here to contact us regarding joining the Integrated Care Social Network.
Thank you!
Governance Committee
Committee Members
| Member Name | Title | Organization |
|---|---|---|
| Stephanie Orlando | Chief Operations Officer | Western New York Independent Living |
| Brittany Tranello | Executive Director | Erie Niagara Area Health Education Center |
| Broderick Cason | Community Engagement & Program Manager | Univera Healthcare |
| Mindy Cervoni | President and CEO | Community Services For Every1 |
| Frank Cerny | Executive Director | The Rural Outreach Center (The ROC) |
| Andrew Davis | Chief Operating Officer | ECMC |
| Al Hammonds | Chief Operating Officer | COPE, WNY / Community Health Center Buffalo |
| Stacy Goyette | Senior Manager, Project Management | HEALTHeLINK |
| Andrea Wanat | Chief Executive Officer | Value Network |
| Pastor George Nicholas | Chief Executive Officer | Buffalo Center for Health Equity |
| Megan Lostracco-Reed | Senior Director, Strategic Initiatives | Catholic Charities of Buffalo |
| Ryan Undercoffer | Executive Director | Matt Urban Human Services Center |
| Tara Burgess | Executive Director | Every Person Influences Children – EPIC |
| Valerie Nowak | Chief Executive Officer | Harmonia Collaborative Care |
| Cindi MacEachon | Chief Executive Officer | Peaceprints of WNY |
| Allison DeHonney | CEO/ Executive Director | Buffalo Go Green |
| LuAnne Brown | Chief Executive Officer | Buffalo Prenatal Perinatal Network |
| Thomas Beauford | President and CEO | Buffalo Urban League |
| CJ Urlaub | Sr. Vice President, Strategic Growth and Partnerships | Catholic Health |
| Mary O’Leary | Director of Community Services | Cattaraugus County, Department of Community Services |
| Heidi Milch | Executive Director | CCNY |
| Carmelo Hernandez | Director of Community Mental Hygiene Services | Chautauqua County Department of Mental Hygiene & Social Services |
| Esmeralda Sierra | President | Hispanic Heritage Council |
| Steve Harvey | Chief Executive Officer | Integrity Partners |
| Doris Carbonell-Medina | Senior Community Development Officer | Lisc, Inc. |
| Concetta Ferguson | Chief Innovation and Program Development Officer | People Inc. |
| Laura Pennington | President and CEO | Pinnacle |
| Bridget Bartolone | SNAPCAP Executive | SNAPCAP |
| Heather Brown | Assistant Executive Director | The Resource Center |
| Trina Burruss | President and CEO | United Way of Buffalo & Erie County |
Compliance and Grievance Hotline
Hotline Details
To submit a confidential Grievance or Complaint please contact us:
Please call our hotline: 716-431-5100, ext. 6, or CLICK HERE to send a confidential email.
We will return your message within 72 business hours if you provide contact information.
For more information about
Western New York
Integrated Care Collaborative,
click here.
