The Bridges to Health (B2H) Waiver Program is designed specifically for vulnerable children with serious emotional disturbances (B2H SED), children with developmental disabilities (B2H DD), and B2H for medically fragile children (B2H MedF). The B2H offers services not otherwise available in the community to children with these complex medical conditions, and does so in the context of their often complicated family and caregiver network. By supporting children in foster care or DJJOY community services supervision in the least-restrictive home or community setting, the B2H Waiver Program provides opportunities for improving the health and well-being of the children served, and supporting permanency planning. The program is designed to provide community-based health care services and supports to children in foster care or DJJOY community services supervision and to those who have been discharged from foster care or DJJOY community services supervision.

The program recognizes that children in foster care or DJJOY community services supervision can have many caregivers involved in their lives. In the program, children  are served in the least restrictive, most home-like setting possible, involving those in the caregiving network, whenever appropriate––foster family, birth family, and adoptive family members.

B2H services complement, but do not duplicate, services provided to these children through other programs, such as foster care or DJJOY community-based initiatives. The children may enter the B2H Program only while in foster care or DJJOY community services supervision, but once in the program they may be eligible for services after  discharge from foster care or DJJOY community services supervision until age 21 if the child remains otherwise eligible.

Health Care Integration Agency

To promote efficiency, regional flexibility, and participant choice, OCFS enters into provider agreements with Health Care Integration Agencies (HCIAs) across the state. Health Care Integration Agencies (HCIAs) are voluntary authorized child care agencies with demonstrated experience in providing operational and administrative functions at such a level as a Medicaid home and community-based waiver would require. The HCIAs work in conjunction with NYC Children’s Services that retain responsibility for making referrals, eligibility determinations, and enrollment decisions.

The HCIAs:

obtain necessary medical assessments;

  • complete application packets for all identified children for consideration for the most appropriate B2H waiver;
  • recruit and work with B2H Waiver Service Providers (WSPs) to offer the full service array to waiver participants;
  • propose Individualized Health Plans (IHPs) to the LDSS that outline the type and amount of services needed by the applicant; (delete)
  • arrange waiver services; and (delete)
  • assist in B2H Waiver Program oversight.


Pre-Enrollment Activities

 assist casework staff in identifying and assessing the need for services for children who are medically fragile;

  • assist casework staff in obtaining necessary medical assessments;
  • assist casework staff in completing application packets for all identified children for consideration for the most appropriate B2H waiver;

Post-Enrollment Activities

provide the service of Health Care Integration, the B2H Waiver service through which the Individualized Health Plan (IHP) is created and managed;

  • assist HCI in the development and update of the IHP;
  • link the child and family/caregiver to the identified services;
  • consult with the child and caregiver on the appropriate provision of services;
  • stabilize the environment for the child and caregiver, and advocate for the child’s needs;
  • participate in the initial team meeting and one team meeting every 6 months
  • coordinate the constellation of services and providers to meet specific needs of each enrolled child; (delete)
  • conduct home/field visits once every other month;
  • facilitate a WSP, HCI/HCIA change as needed; (delete)
  • ensure caseload management, and required service contacts responsibilities are met; this includes speaking with the HCI once a month
  • conduct documentation reviews: Detailed Service Plans, Service Summary Forms (delete), & Progress Notes;
  • meet status change responsibilities; (delete)
  • participate in overall quality management of B2H Waiver Program.
  • Complete the annual level of care form for each child on your caseload

The preferred qualifications for an HCI are:

a Registered Nurse; and

  • a minimum of one year of experience providing service coordination and information, linkages, and referrals for community-based services to children with special needs, individuals with disabilities, or seniors.

In addition the candidate must demonstrate the following:

Proven leadership and management abilities, including meeting deadlines, ensuring compliance with agency policy and procedures in accordance with contractual requirements, developing new initiatives;

  • Demonstrated effective inter-departmental project management and coordination;
  • Excellent writing, communication, motivational, platform, management, organizational, and word processing skills required;
  • Ability to travel to the communities;
  • Ability to work a flexible schedule, including periodic evenings and weekends; and
  • Possession of a valid driver’s license is required.

Required Training:

 First aid/cpr

  • Mandated reporter training
  • Overview of Bridges to Health
  • One day- three month training. Topics include; cultural diversity and child development
  • Three day- six month training: Topics include; HCI roles, writing of a detailed service plan, writing of a progress note