When you climb the porch stairs to the front door of Judith’s home, you’re greeted by a woman with a radiant smile, and immediately sense a palpable warmth. She came to the inner city of Rochester to visit a cousin. While she never imagined she would stay, that’s exactly what she’s done. Her cousin eventually moved away, and Judith found herself alone—her daughter, her closest relative, lives more than five hours away.
Living on her own with no support system, Judith has faced numerous health challenges, including a bilateral knee replacement in 2023. It was during her recovery that she was first connected with a case manager. She didn’t expect her health plan to become a critical means of assistance, but that’s exactly what happened.
“As a former caregiver myself, I never thought I’d be the one needing support. But my care manager at Excellus is everything to me,” Judith says, her voice steady with emotion. “She’s more than just a voice on the phone—she is my lifeline. Whether it’s finding short-term rehab, helping me navigate the health care system, or simply reminding me I’m not alone, she’s there.”
And it’s that care manager who referred Judith to the Community Connections team who are now at her home helping to set up the Excellus BlueCross BlueShield (BCBS) app on her phone, which will allow her to access her identification card, find health care providers, check her medical coverage, track spending, and view claims. But what matters more to Judith is knowing that someone who cares is just a call or a visit away.
In the Field: Bridging the Gap to Better Health
Judith’s experience is just one of thousands. Across upstate New York, the case management and Community Connections teams are working quietly, relentlessly—to meet people where they are, in every sense of the phrase.
While SafetyNet CARE provides personalized phone-based support navigating local community and national resources like Meals on Wheels, Social Security benefits, and Veteran’s Assistance benefits, the Community Connections team takes it further. Established to locate and re-engage hard to-reach, medically fragile Medicaid members, the team is often knocking on doors, walking city blocks, and reaching out to those who’ve lost touch with the care they need and access they deserve. These are individuals who may be homeless, moving between homes, or simply unable to answer the phone.
While Excellus BCBS consists of more than 4,000 employees, the Community Connections team is small. Just seven people serve all 39 counties—yet their impact is immense. Last year alone, they received referrals to reconnect with nearly 6,800 members.
“We are here to serve our communities in any way that is needed to get and keep them healthy – that is the benefit of being a nonprofit, local health plan,” says Dr. Nicholas Massa, vice president medical affairs, commercial products and clinical integration at Excellus BCBS. “Through Community Connections, we may help a member with high blood pressure work with a nurse to keep the member’s health in check, provide special formula for a premature baby to a new mother who may be financially strapped, or acquire beds for family members who may be sleeping on the floor. The ways they are impacting lives are endless … and meaningful.”
Around the holidays, when the world can feel lonely for many, Community Connections shows up with food baskets and kindness. In 2024, they brought Thanksgiving meals to 375 families who might have otherwise gone without.
“Some of the reactions we see from our members when we deliver the baskets are gratitude, excitement, thankfulness, and tears of joy,” says Sylvia Lee, director of outreach and training programs at Excellus BCBS. “We are seeing a lot of food insecurities and a lot of need by individuals … it is such a rewarding feeling that you assisted someone in need.”
Community Connections Thanksgiving Baskets
“Any Day We Connect with a Member is a Good Day”
Dajia Richardson, Community Connections manager for the past six years, understands the significance of this work. She and her team are passionate about addressing health care disparities and improving overall health outcomes in their communities.
“I love that our team is driven by a natural curiosity and finds such satisfaction in making a difference, one member at a time. We don’t just check boxes—we listen, we care, and we persist,” she says. “If we can prevent just one crisis, if we can help someone feel seen, that’s a good day.”
The team has discovered that a personal visit may be more than an official letter or phone call to encourage Medicaid members like Judith. “The work goes far beyond traditional care,” Sylvia says. “It’s about building trust, encouraging prevention, and helping people believe in their own health journey.”
Dajia adds, “I’m proud of the work we do because it centers around increasing access to care, preventive care, and helps reduce long term costs. We make a difference when we catch things sooner rather than later— making certain that members don’t slip between the cracks and connect them to the resources they need.”
A Lifeline That Feels Like Local Family
Before Dajia leaves Judith’s home, Judith turns to her and, with quiet conviction says, “Thank you for giving me hope and being here today. I’ve never seen my care manager’s face, but I know her voice, and when I hear it—I know I’m going to be okay.”
That moment, quiet and deeply human, speaks volumes. “This isn’t about insurance – it’s about people, about showing up and standing beside someone when they need it most, reminding them they are not alone,” says Dr. Massa. “Judith’s care manager and Dajia … they are the faces and the voices of Excellus BCBS. We have a lot to be proud of, thanks to their work. And that’s the heart of our mission.”
The Healthcare Engagement Team helps to ensure that individuals who are uninsured, underinsured, or have limited access to care due to financial or other barriers maintain access to essential health care services through Medicaid and the Essential Plan. The Case Management team at Excellus BlueCross BlueShield (BCBS) consists of nurses, social workers, mental health counselors and physical therapists that collaborate to provide telephonic comprehensive care to our members. They focus on physical, emotional, and social wellbeing to help members feel confident navigating their personal health journeys.
Community Connections is part of the Case Management team at Excellus BCBS in upstate New York. These employees find hard to- reach members to reconnect them with care management specialists. They travel to member’s homes to help them reconnect with the Health Plan and help offer in-person assistance when necessary. For more information about the Case Management or Community Connections programs, please call 1-877-222-1240.
