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GRHHN links patients who have complex chronic conditions to community and care support systems. GRHHN Care Managers link clients with community resources to address food and housing needs. 

Medicaid recipients (includes managed care and dual eligible – Medicaid and Medicare)

  • Adults receiving the majority of their care in Monroe County
  • Those who may have:
    • significant mental illness or serious emotional disturbance
    • HIV/AIDS
    • complex trauma, if under 21
    • two or more chronic health conditions (i.e. asthma, diabetes, heart disease, mental health condition, substance use disorder, etc.

Making a Referral is Easy

Make an ONLINE CARE MANAGEMENT REFERRAL at: or call 585-350-1400 if you have any questions about making a referral.

  • Referrals can also be submitted to GRHHN via fax 585-978-7714 or sent via secure email to
  • Patient consent is required (verbal consent is acceptable)