Adult Community Integration is case management that help adults with behavioral disabilities to build skills & obtain resources to improve quality of life. 

  • Clients choose their clinical & natural supports

  • Customized team planning: Staff and clients create a partnership to identify needs, strengths, skills and resources

  • Clients receive ongoing support from CWC & other providers as needed







Team Planning

Staff and consumers create a partnership to identify needs and determine the strengths, skills & resources necessary to achieve their goals.

The team ensures that the plan remains flexible yet relevant to each individual’s specific needs as progress occurs & changes develop.


  • 18 years old or older

  • Eligible for MaineCare

  • In-patient or recently hospitalized; homeless; incarcerated, as a result of psychiatric symptoms

  • Need assistance with self-care and assuring safety of self & others

Counties Served:






Referrals are encouraged from individuals, family members, medical community, case managers, DHHS, service providers & hospitals 

Contact the Director of Case Management at 564-2464

Behavioral Health Home Services provide a team-based approach to the integration of physical and behavioral services. It supports adults with behavioral health challenges who also need support to improve their physical health and to provide coordination among all their service providers. It also has a *Certified Intentional Peer Support component to assist individuals in developing natural and peer supports in the community. Service recipients may live in their own home, in a group home setting or be homeless. A Behavioral Health Home is not an actual building, rather a service that helps coordinate services.

A.   Clients Served under Adult Behavioral Health Home Services:

  • Must be 18 years of age or older 
  • Must be eligible for MaineCare Services
  • Must have a mental health diagnosis under the Diagnostic and Statistical Manual of Mental Disorders 5, except that the following diagnoses may not be primary diagnoses for purposes of this eligibility requirement:

  • Delirium, dementia, amnestic, and other cognitive disorders;
  • Mental disorders due to a general medical condition, including neurological conditions and brain injuries;
  • Substance abuse or dependence;
  • Mental retardation;
  • Adjustment disorders;
  • V-codes; or
  • Antisocial personality disorders.


  • Has a LOCUS score, as determined by staff certified for LOCUS assessment by DHHS upon successful completion of prescribed LOCU S training, of seventeen (17) (Level III) or greater. The LOCUS assessment must be administered annually and documented in the member’s record.

B.   Services Provided

The Behavioral Health Home Services team consists of a Coordinator who acts in a case management capacity, a Certified Intentional Peer Support Specialist and a Nurse Care Manager. The team consults with primary care and psychiatric providers. Through an assessment and treatment plan, supports can include:

  • Identifying needs related to physical and behavioral care, housing, education, vocation, finance, socialization and development of natural and peer supports
  • Coordination of care among physical and behavioral health services
  • Crisis planning and management
  • Inclusion of family, cultural and religious supports
  • Identifying, obtaining and maintaining resources and benefits in the community as they relate to identified needs
  • One-on-one and group peer support

C.  Waiting List: 

Clients placed on the waiting list are prioritized by the urgency of services and needs.  Individuals who are currently in a hospital or are at risk of being hospitalized are the highest priority.  The waiting list is updated at least every 30 days.

Discharge Criteria

               1.   Individual reached all of his/her goals

               2.   Voluntarily withdrew from services

               3.   Moved out of the area       

               4.   No longer needed services

5.   Required a higher level of services

6.    Refused to work on his/her goals

7.    Was referred to another provider

               8.    Passed away 

Prior to any client being discharged, a discharge meeting will be scheduled, unless there are extenuating circumstances.  At this meeting, the client’s team will discuss what his/her needs continue to be, needed Releases of Information forms are signed in order for the team to make appropriate referrals or release information to other agencies.  CWC will not discontinue or otherwise interrupt services of a class member without obtaining prior written approval from DHHS.    

* A Certified Intentional Peer Support Specialist  is an individual who has completed the Maine Office of Substance Abuse and Mental Health Services (SAHMS) curriculum for CIPSS, and receives and maintains that certification.

Funded in part by the State of Maine Department of Health and Human Services.