Seeking to Improve Health Outcomes in Tompkins, Tioga and Cortland Counties
Navigating the health care system can be overwhelming, especially for families who have children living with complex and chronic challenges.
For such families, life can be thrown into chaos and disrupted at a moment’s notice. Worry, confusion, fatigue, and time away from school and work can create additional stress well beyond the initial event that triggered upheaval.
Overtime, children and parents can lose hope and feel disempowered. They may feel isolated and uncertain about their ability to stay together as a family.
Fortunately, improved care coordination and service integration are accessible through the Health Home* care management service model. A Health Home is not a physical place, but rather a network of organizations and caregivers, coordinated by a Care Manager, who communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner.
As a member of the Children’s Health Homes of Upstate New York (CHHUNY) Network, WGA offers Care Management Services for children and their families in Tompkins, Tioga and Cortland Counties. Services are guided by the belief that every family has strengths and that families are the natural and most effective drivers of their care. They are provided at no cost to eligible families.
Children from birth to age 21 are eligible for Care Management Services provided they meet the following criteria:
- they are enrolled in Medicaid
- they reside in a CHHUNY New York State county
- they have significant behavioral, medical or social risk factors which can be addressed through care management AND meet eligibility criteria by having two or more chronic health conditions from the DOH eligibility list OR one of the following single qualifying conditions: HIV/AIDS, Serious Emotional Disturbance or Complex Trauma.
Families who maintain eligibility (as noted above) and communication with their Care Manager or care management agency continue to receive Care Management Services until they meet the goals they set for themselves through the program. If desired, Care Management Services can be accessed again in the future provided prior goals have been reached and Department of Health eligibility standard requirements continue to be met.
The Care Manager’s Role
A Care Manager is an advocate who works collaboratively with individuals and families wherever most convenient and private for the client, be at the family home or at WGA’s campus. Care Managers are trained to identify the strengths of each family, assess the opportunities for additional support, develop a plan of care centered around the goals of identified by the family and assist in making linkages to supports. Examples of additional supports may include services beyond traditional medical care, such as housing, legal assistance and helping a person become involved in social or community activities.
WGA Care Managers live in the same communities as the families they assist. They are also well-poised to understand the breadth and complexities of the needs facing families who have children living with complex and chronic challenges. WGA has more than 120-years of experience working with youth and families, a proven ability to link families with appropriate community services based on their need, and a strong track record of success working with diverse populations.
Children and families can expect a WGA Care Manager to:
- Listen to the family to come up with a collaborative plan of care centered around goals identified by the family
- Help to improve the care a child receives in medical and mental health services
- Help reduce other barriers to the family such as unemployment, housing and access to health and counseling services
- Help streamline care to get the best fit of services for a family’s unique circumstances
- Ensure continuity of care from inpatient to other settings, including follow-up services
- Make referrals to community and social support services
- Help families learn to navigate patient portals and use technology to access a child’s medical information
- Maintain confidentiality
- Provide individual and family support, as guided by the family
For more information about this program, please contact: