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Caring Beyond the Clinic: How Jericho Road’s Care Coordination Team Walks with Our Neighbors in Need

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At Jericho Road Community Health Center, we know that health is shaped by far more than medicine. Access to food, stable housing, warm clothing, and social support can make just as much of a difference as a prescription or doctor visit. That’s why our Care Coordination program is such a vital part of Jericho Road’s work here in Buffalo.

Our Care Coordinators walk alongside patients who are navigating complex medical and social challenges. They create individualized care plans that take into account each person’s health conditions, family situation, and community supports. They coordinate medical appointments with primary care providers and specialists, help patients understand their treatment plans, and assist with insurance paperwork and applications. They also advocate for patients facing financial or systemic barriers and connect them to community resources that address the social determinants of health.

Our care managers often begin by listening to what matters most to the individuals they serve. The goals are deeply personal and aspirational: “I want to be healthy and enjoy my family,” or “I want to become a citizen and vote.” These dreams are grounded in everyday hopes too like learning English to better speak with their children, finding a job, or simply being able to walk around the park. As goals are reached, new ones evolve.

A gentleman was referred to the care management team by his medical provider: He had lost his leg in his home country when a bomb struck his family’s business. Needing a prosthetic to walk, he was considered lucky as some of his family members lost their lives that day. Unfortunately, his prosthetic leg was old, maybe from the 70s, and he was in constant pain. As he immigrated to the US, walking was difficult, and navigating this new healthcare system even more so. The orthotics clinic he was referred to was kind, but without interpretation services, communication broke down. Frustration mounted on all sides.

Sue, one of our care managers, stepped in. She accompanied him to every appointment, ensuring he had language access and support. When he finally received a new prosthetic leg and put it on, he took off running. Tears streamed down his face as he cried out, “I love America.”

This man was the sole provider for his family—his mother, two sisters, and a niece. Though some suggested he apply for SSI, something he would eventually be eligible for, his dream was to work. And now, he does. Full-time. He provides for his family with pride and dignity.

When asked what he wanted most in life, his answer was simple and heartfelt: “To provide for my family, get married, and have kids.”

This work is deeply personal. Every day, our Care Coordination team meets people who are in crisis—families who need food that same day, parents without enough winter clothing for their children, or elderly patients struggling to keep up with both medical needs and daily living costs. Having emergency supplies on hand allows our team to meet those urgent needs right away, offering a moment of dignity and relief while we connect patients to longer-term solutions like food pantries, clothing closets, and housing resources.

 

Join Our Holiday Drive

As winter approaches, Jericho Road is launching a Holiday Drive to support this vital work. You can make a difference by donating any of the following items:

  1. Food Kits – Shelf-stable, nonperishable foods that can sustain an individual or family for a few days.
  2. Hygiene Supplies – Soap, shampoo, toothpaste, deodorant, lotion, and toilet paper.
  3. Winter Kits – Gloves, hats, socks, and other warm essentials for Buffalo’s coldest months.

These donations go directly to our Care Coordination team, who distribute them to patients in immediate need. Every kit helps bridge the gap between crisis and stability — and reminds our neighbors that they are seen, supported, and cared for.

 

Beyond Basic Needs

In addition to meeting emergency needs, the Care Coordination team also helps patients build long-term stability through social connection, transportation training, housing navigation, and health fairs focused on preventive and seasonal care. These efforts ensure that families not only survive, but begin to thrive — connected to the resources and relationships that foster lasting health.

 

How You Can Help

Donations can be dropped off at 181 Barton St, Buffalo NY on:

11/11 from 7am-12pm

11/12 from 12pm-4pm

11/14 from 10am-2pm

12/2 from 12:00-4:00pm

12/16 from 10:00 – 2:00pm

Please let us know in advance what time you’ll be stopping by:

Margie 716-346-3640 or Margie.Soto@jrchc.org

Serreh 716-346-3639


You can also make a financial gift online at www.jrchc.org/donate-today to support this work year-round.

At Jericho Road, care doesn’t stop at the clinic door. With your help, we can continue to meet people where they are — with compassion, dignity, and hope.

 

Make a monthly or one-time donation today

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