Preferred Communities Intensive Case Management (ICM) MINNESOTA COUNCIL OF CHURCHES REFUGEE SERVICES SARA LIEN, MSW, LISW MARY KELSO, MSW

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1 Preferred Communities Intensive Case Management (ICM) MINNESOTA COUNCIL OF CHURCHES REFUGEE SERVICES SARA LIEN, MSW, LISW MARY KELSO, MSW

2 Program Overview Preferred Communities Programs from the Office of Refugee Resettlement that support the resettlement needs of particularly vulnerable refugee (and other ORR populations) communities that require specialized and extended case management Enhancement of refugee services providers capacity to resettle and support vulnerable populations in their agencies and communities

3 Eligibility - Vulnerable Populations Complex medical needs and disabilities MCC focus area Mental health conditions or challenges MCC focus area Single parents Women at risk LGBTQ HIV positive Youth without parents

4 Eligibility Immigration status and length of time in U.S. Must have ORR approved immigration status: Refugee MCC serves primary and secondary migrants Asylee been granted asylum asylum seekers not eligible Cuban/Haitian entrant Afghani or Iraqi SIV Amerasian Victim of Trafficking Unaccompanied Refugee Minor with Special Immigrant Juvenile Status or U Status Have been in the U.S. five years or less

5 Extended Case Management Requires at least six months of support from case manager Each client has an extensive initial assessment to identify areas of need, strengths, and possible barriers to success Quarterly assessments track progress - service plan is adjusted as needed throughout service timeline to adequately respond to progress, change of condition, or emerging need in other areas (financial, housing, immigration, family relations, social adjustment) Ultimate goal is reaching self sufficiency being able to manage condition and navigate health system independently as client, family, and community resources allow Program allows one year of services with possibility to extend if client hasn t reached self sufficiency

6 Services For primary refugee arrivals Pre-arrival medical review and preparation for needs upon arrival, such as: Immediate hospitalization Specialized housing and equipment Expedited appointments within first week of arrival Preparation and education of agency staff Connection to providers before arrivals MDH, specialized care, DHS Mnsure Discussion with client s U.S. tie (family or friends) to prepare them for type of condition client has and need they may bring

7 Services Post-arrival Enrollment in expedited insurance (if eligible) Connection to appropriate primary and specialty care Education for client on condition and proper management of condition building and managing expectations Transportation to medical or mental health appointments Care coordination once primary care provider is established and referrals made Assistance with accessing medication at pharmacy education on proper use of medication and getting refills Access to medical equipment Training in use of medical transportation

8 Services Facilitate access to PCA, disability, and other eligible waivered services SSI application and advocacy Connection to legal services Assistance with finding affordable, safe housing Enrollment of children in special education programs Extended cultural orientation Linkages to social supports Assistance with arrangement of funerals if needed while enrolled

9 Services Access to culturally appropriate mental health supports: Therapists ARMHS workers Advocacy in mental health system Crisis response and psychiatric hospitalization support Psychoeducation for client and family Cultural education for providers

10 Services Advocating for clients within larger healthcare system Attending appointments with client Acting as a liaison between provider and client Supporting questions and choices of clients and families Educating clients and providers throughout process to ensure that information isn t lost or misinterpreted Assessing and responding to client expectations of system and providers Regular home visits with client

11 Building strong networks of culturally literate and client-centered providers Trainings and presentations to providers in the community on how to best meet the needs of refugee patients Informal education while with providers in their settings Outreach to providers in the community to education on our specialty areas and collaborate with programming Accessible resource for professionals in the community who have questions about working with new refugees

12 Supporting clients Helping our clients to feel confident in their own ability to communicate their needs and expectations to providers Building empowered families and clients who are able to access the care that can assist them in successfully integrating into their new communities Identifying and focusing on strengths so clients feel that despite their conditions, they can be valuable, contributive members of their families and communities Culturally informed, client-centered relationships

13 Taking referrals! MCC is currently taking referrals for our ICM program! Sara Lien Program Manager Or Mary Kelso Refugee Program Specialist: Refuge Health