Care Management

Josh WindowAt Trillium Health, we use a patient/client-centered approach. This means that patients/clients decide what they want to work on and we provide them with the necessary supports to be successful. When we first meet with patients/clients, we help them to identify their needs and develop a plan to meet those needs.

We advocate with other service providers to ensure that services are provided in a timely and respectful manner. We help the patient/client to gather all of the available information and then support the patients/client to make their own decisions. Patients/Clients can access our services at our Rochester, Bath and Geneva offices, and interpreting services are available.

Care Managers can:

  • Coordinate services among providers
  • Link clients with appropriate services
  • Monitor needs for crisis prevention
  • Improve medical compliance/adherence
  • Follow up regarding specialty care
  • Coordinate transportation 
  • Address housing needs
  • Assist with other psychosocial needs (support systems)
  • Coordinate referrals and follow through for mental health, substance abuse, clothing, legal assistance, budgeting, debt management, and domestic violence
  • Advocate for client needs
  • Coordinate benefits and entitlements (SSI, SSD, DSS/DHS Public Assistance, food stamps, Unemployment Insurance)
  • Provide insurance assistance (ADAP, private insurance, Medicaid and Medicaid spendown, Medicare Part D)
  • Coordinate risk prevention for HIV positive people
  • Provide support and education to clients’ families, partners, and friends
  • Assist in obtaining appropriate Social Security or Department of Health and Human Services benefits.
  • Provide support services, such as short-term crisis intervention and support groups.
  • Design service plans to ensure that basic needs are being met.
  • Connect patients with other service organizations and/or make referrals to a care manager, who can assist with:
    • Securing safe and adequate housing, clothing and food
    • Transportation to medical visits
    • Advocacy in the community
    • Massage and acupuncture services
    • Legal services
    • Domestic violence services
    • Veteran's services