Seeing Each Other Clearly: MCC’s Intensive Case Management Program Helps Refugees and Health Providers Work Together

Have you ever wondered how newly-arrived refugees with complex illnesses find the care they need in the US? The health care system is incredibly complex, and navigating it successfully takes specific skills and self-advocacy. MCC has developed an Intensive Case Management (ICM) program to meet this particular need. In order to share more with you about how we assist some of the most vulnerable refugees we meet, I talked with our ICM Team Manager, Sara Lien, about the program.

Sara has a Master of Social Work degree and has worked with refugees and immigrant youth in a variety of settings from private practice to high school programming and a Karen women’s healing group.

What is the Intensive Case Management program?

The ICM program was created at MCC in response to the needs we saw in new refugee families with complex health or mental health conditions. Over time, it has become more and more holistic, allowing us to address the transportation, housing, and access issues that are part of living with a health condition. We only enroll individuals who will need treatment for at least 6 months and we usually work with them for 6-12 months in this program.

We work with individuals and family members to help them get connected to appropriate providers and then work with them to achieve self-sufficiency in managing their care.

What does that look like in real terms? What kinds of activities does it involve?

We help connect them with appropriate providers and help make sure that the refugee and their doctors understand each other well. That can involve teaching individuals about their condition, right down to biology and physiology, and helping doctors understand the individual’s expectations and thoughts about the condition. We also help refugees learn how to make appointments, schedule medical transportation, follow up with their insurance company, and get medical equipment.

I look at the medical reports of each refugee as soon as we learn that they may be coming to Minnesota through our office and communicate with IOM (the agency that coordinates refugee travel) about refugees that may need immediate hospitalization or treatment upon arrival. For new arrivals with complex health issues, one of our ICM staff will be at the airport to greet them and make sure we can assess their health right away.

In addition to new arrivals, we are also able to help refugees who have been here for up to 5 years that are facing a new health crisis or who never were adequately treated for a condition.

Can you share the story of family that really impacted you?

There was a young Somali boy who arrived last year with his large extended family. Both of his parents had died in Somalia, so he was being cared for by his grandparents, aunts, and uncles. At 6 years of age, he only weighed 22 pounds and was severely malnourished because weak muscle control made it nearly impossible for him to eat. He still had tons of energy and was very delightful and engaging, and his family was exhausted from providing constant care. They were so excited for him to come to America because they believed that doctors here would cure him.

We connected him immediately to a great care team at Children’s Hospital of Minnesota. We let the doctors know about the family’s hope for his complete healing, and helped the family process the devastating news that he would always have cerebral palsy, but that the care team could help him to live and adapt well. He started physical and occupational therapy, got a wheelchair, and received adaptive equipment for the home. We also helped set him up with special education services at school, personal care assistants to help support his family in his care, and SSI to help with expenses.

We see this family as a real success story. This little boy is doing well in school and enjoying life with other kids and his family. His family has gotten the support they need and understands the role of the supportive services in their lives.

With all the difficult situations you encounter, what do you enjoy most about working with this program?

I love the teaching portion of this position. I enjoy assessing their understanding of their health and then coming up with explanations that are culturally appropriate. It’s really fun to see people begin to manage their own health and feel better! It’s a hard job, but the refugees I work with are so thankful to be in a place where they have access to good care. I also really enjoy training providers and other social-workers so that their own work can be more trauma-informed.

If you could send a message to the providers that will see your refugee clients, what would it be?

Please, treat them like you would anyone else. Acknowledge their humanity, listen to their story, and let that story guide the way you interact. It’s easy to feel shuffled around when you are the patient in a medical space, but it doesn’t take that much time or effort to make an individual feel welcomed. Just take a moment to welcome the presence that’s there.


We are so thankful to have such a caring, competent, and creative individual on our team, helping to care for some of the most vulnerable refugees we meet. You too can be a part of this incredible program at MCC by making a financial donation.




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