Care That Connects. Outcomes That Last.
At Elm & Oak, care management isn’t a box we check. It’s a partnership we build. Whether it’s meeting individuals in the community, supporting transitions from hospital to home, or addressing the social drivers that impact care plans, we show up where we’re needed. In person, in the office, or by phone, we meet individuals where they are so they can get where they need to be.
Care Management Starts With Identification
Effective care begins with understanding who needs support and why. We use clinical and claims data, provider referrals, and predictive analytics to identify gaps, stratify risk, and reach individuals early.
Once enrolled, clients are paired with a care team that works alongside providers to close gaps, manage chronic conditions, and address the clinical and social needs that influence outcomes.
What Makes Our Model Work
Whole-Person Support
A population-based model that addresses clinical needs and the social determinants of health, including food, housing, and transportation.
In-Person Engagement
We meet clients at home, in clinics, or in the community to build trust and strengthen follow-through.
Education & Empowerment
We coach individuals and families so they can navigate care independently over time—a “teach to sustain” approach.
Seamless Coordination
We integrate with primary care, specialists, hospitals, and community partners to create unified care plans.
Data-Driven Decision-Making
We continuously measure outreach and outcomes to refine interventions and improve performance.
Our Care Management Programs
Elm & Oak’s care management umbrella includes multiple high-touch services tailored to different levels of need.
Case Management
Intensive, individualized support for people with complex medical, behavioral, and social challenges. We focus on:
- Advocacy and barrier reduction
- Short-term or event-driven support
- Smoother transitions following hospital or post-acute care
Disease Management
Structured, evidence-based programs for chronic and high-risk conditions such as asthma, diabetes, and prenatal care. These programs:
- Emphasize education, lifestyle change, and self-management
- Follow standardized protocols to reduce exacerbations and hospital use
Health Home Care Management
As a Health Home Care Management Agency, we support Medicaid members with complex needs across Rochester, Binghamton, Syracuse, Buffalo, and Albany. We partner with multiple health plans and community providers to deliver close-to-home support that is culturally responsive and accessible.
Our long history with low-income and vulnerable populations helps us find, engage, and stay connected with members who are often hardest to reach. Within the Health Home framework, we provide:
- Comprehensive care management
- Care coordination
- Health promotion
- Transitional care and follow-up
- Patient and family support
- Referrals to community and social services
What We Proactively Address
Contact UsOur programs are designed to intervene early, reduce risk, and sustain long-term improvement. We support:
Complex and chronic conditions- High-risk pregnancies and maternal care
- Behavioral and mental health
- Pediatric needs and family support
- Post-acute and transitional care
- Medication adherence
- Social determinants of health
Let Our Expertise Drive Your Success
With decades of experience in navigating care coordination for vulnerable populations, we know what it takes to engage individuals and move the needle on quality.
Our model is not about adding complexity, it’s about amplifying impact. We function as an extension of your team, helping you achieve better outcomes with less friction.
Let’s Coordinate Better Care—Together
Want to reduce readmissions, boost engagement, and support whole-person health?
Connect With Us