Medically Complex Case Care Coordination
The Medical Case Care Coordination Program provides coordination, support, and resources for newcomers who arrive with acute or chronic medical needs that are beyond the scope of the routine Refugee Health Assessment and require connection to primary care.
Overview of Complex Case Process
Referrals
It is important to promptly notify the Minnesota Refugee Health Program (MRHP) about newcomers with medical needs to ensure their access to appropriate, timely health care.
- Referrals should be made pre-arrival when possible or, at the latest, within 7 days of arrival using the New Arrival Notification and Screening Referral form.
- Each resettlement agency determines the process by which they will identify medical cases pre-arrival.
- Referrals should include all available health information such as biographic information, Significant Medical Condition (SMC) forms, and overseas medical exam forms.
Care plan development
After receiving the referral, the MRHP Health System Coordinator will develop a care plan for the client. Open care plans will be updated and shared with resettlement agencies as they are completed. The Health System Coordinator will:
- Collaborate with the MRHP Refugee Health Nurse to determine appropriate referrals, develop resources, identify, navigate, and work with health systems, and assist local public health, providers, and resettlement agencies to meet clients’ health needs.
- Oversee care plan implementation, coordinating with the resettlement agency point person and case managers who implement the care plan objectives.
- Monitor care plans to identify follow-up and referral needs, record progress, avoid duplication of services, and address clients’ needs proactively, whenever possible.
Care plan implementation
Resettlement agency case managers, the Health System Coordinator, and other staff listed in care plan objectives implement the activities of the care plans, mindful of the due dates and best practices for each objective.
- The resettlement agency program manager ensures that an MRHP release of information is saved in each arrival’s case file, signed as soon as possible by the client. This allows the MRHP Refugee Health Nurse and Health System Coordinator to access and share medical information to coordinate appropriate care.
- The resettlement agency point person meets with the Health System Coordinator monthly to review and update care plans and brainstorm resources.
- The Health System Coordinator identifies strengths and challenges resettlement agencies have in completing care plan objectives and discusses solutions with the resettlement agency team.
- The Health System Coordinator, Refugee Health Nurse, resettlement agency program managers, case managers, local public health nurses, and providers communicate to ensure clients’ health needs are met.
Best practices for common care plan objectives
- Obtain wheelchair or special transport pre-arrival for use upon arrival, if needed.
- Ensure adequate medication supply within one day of arrival.
- Expedite Medical Assistance (MA) within 3 days of arrival.
- Expedite Refugee Health Assessment or primary care prior to meds running out or within designated time.
- Make urgent referrals to specialists or surgery within the designated timeline, often within 1 or 2 weeks after arrival.
- Establish primary care by choosing a primary care clinic and making a new patient appointment to ensure ongoing access to care.
- Additional medical referrals most often occur via primary care.
- Ensure Prepaid Medical Assistance Program (PMAP) matches primary care provider by helping client choose a PMAP plan or by sending in the form proactively once the client’s choice is known. This is done within approximately one month after MA approval.
- Alert MRHP Refugee Health Nurse and Health System Coordinator about hospitalizations or Emergency Department visits as soon as you become aware of the situation. Provide the date of the event and name of the hospital.
- Achieve independent access to care within 90 days after arrival. Client should be able to access primary, specialty, and emergency care and obtain prescription refills without the assistance of the resettlement agency prior to closing the case.
- Refer to Preferred Communities (PC) Program (extended case management), as appropriate. The resettlement agency program manager and MRHP Health System Coordinator may determine if a referral to PC for extended case management is appropriate.
Supportive services
