Refugee and Immigrant Self-Empowerment

Care Management

Making Healthcare Accessible

What I a Home Health? 

  • A home health is a service to ensure effective coordination and management of care by ensuring all those involved in an individual’s care are working together to support a person’s recovery and overall health. 
  • It was created to ensure members get the services they need to connect and get regular guidance from a Care Manager on navigating the medical system in the United States.
  • Health homes help minimize preventable emergency department visits, establishing care with general practitioners and making sure members are developing a better relationship and understanding with the medical system overall. 

What is our program?

  • Our program helps refugees and immigrants communities by assessing their health care needs and creating a personalized care plan. We work to coordinate behavioral and physical healthcare needs of each patient by ensuring they are connected to the right healthcare providers. Care Managers work to connect members to services and providers such as physical therapists, specialty care practitioners, pharmacist, counselors (mental and health substance abuse), physicians, as well as social and legal aid, etc
  • Our care managers become advocates for the care recipients by conducting ongoing assessments and care plans to monitor and implement changes according to the individual needs of each client.
  • Our care managers also assist with general care coordination by helping clients schedule medical appointments and partnering with the member’s doctor and a team of healthcare providers to help bridge gaps in healthcare connectivity.

What makes RISE Care Management unique?

  • RISE Care Management aims to try and connect disadvantaged immigrant and refugee communities with as many services as possible by partnering them with a Care Manager that can speak their language.
  • The Care Managers that RISE employs are respected community members that can communicate and navigate the complex cultural/social and language spheres of our clients.
  • Currently, our Care Managers speak a combined total of 10 unique languages and dialects, not including English. 
  • Our overall goal is to make healthcare more accessible to disadvantaged communities through the efforts of our Care Managers to build a partnership of trust with our clients.
  • RISE Care Managers are able to work with the diverse web of programs that RISE offers to connect clients to Bridging Case Managers, Employment Assistance, Education Coordinators and IDA Program assistance. Ideally, our clients as well as their family members will be able to receive support in many different areas of their lives apart from just healthcare connectivity.

Who we partner with?

  • We collaborate with our lead Health Home provider, St Joseph’s Hospital through St. Joe’s Care Coordination Network.
  • We also collaborate with managed care organizations (MCO) like Molina, Fidelis, and United Healthcare.

Eligibility Requirements

  • To be eligible for health home services, an individual must be enrolled in Medicaid.
  • An individual must have two or more chronic conditions or one single qualifying chronic condition. 
  • Two or more chronic conditions may include asthma, diabetes, mental health condition, heart disease, substance abuse disorders, obesity, etc., 
  • Single qualifying chronic conditions according to New York State are HIV, and Serious Mental Illness (SMI).
  • Individuals must also have significant social risk factors, including inadequate housing, lack of access to transportation or food, non-adherence to treatments and medications, high ER usage, lack of healthcare connectivity, a recent release from incarceration, and lack of social/family support.