The Arc of Monroe’s Health Homes Care Management team is one of 28 care management agencies contracted through the Greater Rochester Home Health Network (GRHHN). Care Management’s role is to coordinate care that a person might need in order to sustain a healthy lifestyle. This care coordination is for people who have an identifying need such as a mental health diagnosis or a chronic condition. These people do not have to be affiliated with The Arc of Monroe or have an intellectual or developmental disability. They just need to have qualifying diagnoses.
Health Homes Care Management is not a health home itself. GRHHN is the health home and the care management team at The Arc of Monroe is contracted through them to help individuals find health services. The care management team also does not provide health services. Instead, they direct them where to go and how to go about reaching individual health goals.
Care Management helps coordinate a variety of health services including directing people with doctors and hospitals, helping them fill out forms and applications, helping them make phone calls to set up appointments or find the answers to their health questions, and connecting them with community resources. But they also help them look for housing, set up transportation, find food pantries and consignment shops to ensure they have bedding, clothes, and any other basic necessities. Theresa Knopp, Health Homes Manager says getting the person to reach their health goals is their overall goal. “One of the most important things for me that I’m passionate about is that they’re not alone and they feel supported.” She says this is even more so when the person has no social network or family.
With Care Management, one of the first things they do when someone is assigned to them is set them up with a plan of care. It’s a person-centered plan to ensure the people are working on whatever individual goals they have to a healthier lifestyle, whether that be staying out of the hospital, learning how to set up appointments, or get a roof over their head. The assistance the person receives from care management can then change based on needs, and sometimes it’s a phone call to the person to see how their doctor’s appointment went or whether they were able to schedule transportation.
It may however be difficult to get help from care management if you are not in a position of high risk. Health Homes Care Management is mostly for those with high risk factors including, needing regular diabetes checks, being a victim of violence, living in unsafe housing, being recently released from incarceration, or having multiple inpatient stays within the past year. It also could depend on capacity at the time of referral. If someone is referred to The Arc of Monroe for their Health Homes Care Management, the program there must have room to take you. If not, you may be referred to a different agency contracted through GRHHN.
If you’re looking for care management, the best way to get it is to check out our website at arcmonroe.org/health-homes or GRHHN’s website at grhhn.org. The Arc of Monroe’s Health Homes Care Management team is also going to focus upcoming efforts on outreach to bridge the gap between care management and homeless shelters.