Care Management
Making Healthcare Accessible
Providing personalized healthcare coordination and support for refugee and immigrant communities
Learn About Our ServicesWhat is Care Management
Care management is a one-on-one healthcare service to patients to help create and manage their care plans. Care management provides direct support, working closely with their patients to assess their needs and wants and determining what type of care is required.
Care management is a team of professional care managers performing administrative duties and coordination on behalf of their patients. Care management in healthcare is a natural extension of primary care. To make that ideal a reality, however, a comprehensive care management program requires complex coordinated interaction among all healthcare stakeholders, from practices, health systems, and care teams to caregivers, patients, their family, and their communities.
Our Mission
Care Management 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.
Care Management Roles
Relationship Building
Building close relationships with patients and their medical care provider(s) by visiting patients in their homes.
Appointment Coordination
Making medical appointments for patients and coordinating transportation to appointments and medication.
Care Plan Improvement
Discussing care plan to find areas for improvement by researching the legality of patient care plans and educating the client.
Care Management at RISE
RISE care management department has a team of dedicated, diverse, and professional care managers who use their skills to work closely with patients, their families, medical care providers, and other stakeholders to serve their communities. They are equipped with the required training and tools and possess the necessary knowledge to support their clients' health issues and treatment requirements.
Care Manager Skills
- Positive attitude
- Communication skills
- Negotiation skills
- Emotional support
- Teamwork and collaboration
- Clinical skills
- Networking with professionals
- Task delegation
What is our Program
Our program helps refugee and immigrant communities by assessing their healthcare needs and creating a personalized care plan. We work to coordinate the behavioral and physical healthcare needs of each patient by ensuring they are connected to the right healthcare providers.
Our Care Managers work to connect members to services and providers such as physical therapists, specialty care practitioners, pharmacists, 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.
RISE Care Management Benefits
Direct Patient Benefits
- A dedicated care manager
- A comprehensive care plan
- Medication and care-management support
- A hospital-to-home program
- Patient education materials
- Expanded communication between patients and healthcare professionals
Healthcare System Benefits
- Care coordination with community and home-based service providers
- Improved clinical outcomes
- Reduced use of high-cost acute care services
- More primary and/or preventive care visits
- Fewer duplicative tests and procedures
- Higher patient satisfaction
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.
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 works with the diverse web of programs that RISE offers to connect clients to Bridging Case Managers, Employment Assistance, Education Coordinators, and IDA Program assistance.
Who do we partner with?
Health Home Providers
We collaborate with our lead Health Home providers:
- St. Joe's Care Coordination Network (SJCCN)
- Health Home of Upstate New York (HHUNY)
Managed Care Organizations
We also collaborate with managed care organizations (MCO) like:
- Molina
- Fidelis
- Excellus
- Humana
- United Healthcare
Eligibility Requirement
To be eligible for health home services, an individual must be enrolled in Medicaid or Medicare and meet one of the following criteria:
Chronic Conditions
Two or more chronic conditions such as asthma, diabetes, mental health conditions, heart disease, substance abuse disorders, obesity, etc.
Single Qualifying Condition
One single qualifying chronic condition according to New York State: HIV or Serious Mental Illness (SMI)
Social Risk Factors
Significant social risk factors including inadequate housing, lack of access to transportation or food, non-adherence to treatments, high ER usage, etc.