Care Management Overview Coordinated care for complex challenges

Care management is a set of activities intended to improve patient care and reduce the need for medical and other human services by enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions. Service providers are encouraged to communicate with one another so all of the individual and family’s needs are addressed in a comprehensive manner. This work is done through a Care Manager.

At Catholic Family Center, Care Managers focus on whole health, including; substance abuse, mental and behavioral health, primary care, social support, academic achievement, psycho-social and financial improvement, as well as coordinating activities with providers.

On "Health Homes"

A Health Home is a group of health and community agencies that have agreed to work together to help people with many health issues get what they need to keep them healthier and safer in the community. Each person who joins gets a “care manager.”

This is a way to coordinate care for our Medicaid patients who have complex chronic diseases and mental health challenges. While many Medicaid patients are relatively healthy, there are several groups whose conditions are more severe, requiring support and assistance in the community.

Services Provided by Care Management

For information on other Supportive and Employment Services for Health Homes clients: Home and Community Based Services

Recovery-oriented programs designed to build stability on a person's individual path to recovery.

Adult Health Homes Getting the care and services you need to stay healthy

Contact Information:

  • Address:

    1645 St. Paul Street, Rochester, NY 14621

  • Phone:

    (585) 546-7220 x6863

  • Fax:

    (585) 546-2607

  • Email:

    cleaks@cfcrochester.org

About the Program

A Catholic Family Center Care Manager will help make sure everyone involved in an individual’s care is working well together and sharing information that is important to support a person’s optimal health and wellness. Our Care Manager supports services that an individual may already be receiving and will help them get new ones if necessary.

Our Health Home Care Manager’s role is to build linkages and bridges to other community providers, and to enhance the coordination and integration of primary and behavioral healthcare to better meet the needs of those with multiple chronic illnesses.

Services Provided

  • Connecting to health care providers,
  • Connecting to mental health and substance abuse providers,
  • Connecting to needed medications,
  • Help with housing,
  • Social services (such as food, benefits, and transportation) or,
  • Other community programs that can support and assist you

Eligibility Criteria

In order to be eligible for Health Home services, the individual must be enrolled in Medicaid and must have:

  • Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes) OR
  • One single qualifying chronic condition: HIV/AIDS or
  • Serious Mental Illness (SMI) (Adults) or
  • Serious Emotional Disturbance (SED) or Complex Trauma (Children)

Children and Youth Health Homes Addressing family needs appropriately

Contact Information:

About the Program

A Children’s Health Home is a community-based care management program that provides comprehensive, person-centered, family-driven care planning for Medicaid members with high needs.

At Catholic Family Center, our Children’s Health Home program goal is to ensure all of the child’s/youth’s providers communicate with one another, and all aspects of care and social, behavioral, medical, mental, and academic needs and goals are met and coordinated. Our Health Home Care Manager’s role is to build linkages to community supports and resources, as well as to enhance the coordination and integration of primary and behavioral healthcare to better meet the needs of children and youth with multiple chronic illnesses.

Services Provided

  • Connecting to other health care providers
  • Connecting to mental health, and substance abuse providers
  • Helping to obtain needed medications and medication management
  • Advocacy and support in medical, mental, academic and court settings
  • Housing assistance
  • Medical appointment transportation
  • Link to other social services, such as food, benefits, and locating transportation
  • Connecting with other community supports, and develop life skills
  • Programs to help with economic and financial improvement
  • Employment Services, such as job training, resume building, interview skills, and job application assistance
  • Assistance in maintaining a job
  • Assistance with improving academic achievement
  • Help obtaining a GED, and much more!

Eligibility Criteria

The child or youth must be under the age of 21; and

  • is currently Medicaid-covered or able to qualify for Medicaid; and
  • has a chronic health, medical, and/or mental health condition (e.g., ADHD, Depression, Anxiety Disorder, Asthma, Diabetes, Sickle Cell Anemia, PTSD, Learning Disorders, Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), or obesity), or
  • has HIV/AIDS, or
  • a serious emotional disturbance, or
  • has experienced trauma

Early Intervention Creating opportunities for children with disabilities or developmental delays

Our Early Intervention services are provided in coordination with our Children, Youth and Family care management services. Visit the Early Intervention site.

Who is CFC

A quick overview of Catholic Family Center

500+
Employees & Volunteers
40+
Programs
19
Locations
1
Mission
Providing the most vulnerable with hope