Community
Finding help with food, housing, transportation or care management can be difficult. It can be especially difficult for someone already managing a chronic condition, financial stress or a major life change. In New York, Mom’s Meals care navigators are helping make that process more personal and easier to navigate. Amira Lindbloom, program manager of care navigation at Mom’s Meals, knows what those she helps are going through. She’s lived it herself.
A career built on walking alongside people
Amira Lindbloom brings nearly 25 years of government and nonprofit experience to the care navigation program, always working with vulnerable and marginalized populations. With a bachelor’s in human services and a master’s in public health, her career has included administering public assistance benefits, helping people more toward self-sufficiency and getting California community supports programs started in community health centers that connected individuals with enhanced care management.
Lindbloom’s commitment is also personal. She knows firsthand how much it can matter when someone offers practical navigation for benefits and services, and respectful support that builds trust during a difficult time.
She received support and services herself. That experience shaped her career and her approach to care navigation: listen carefully, reduce barriers and treat each person as more than a referral. She considers it an honor to be able to walk alongside others in their journey like others did for her.
It was her work with California Community Supports that she first heard of Mom’s Meals. “I would connect my referrals who qualified for medically tailored meals with Mom’s Meals. When I followed up with clients, they would be so pleased with the meals and the service they received and when they called in,” shares Lindbloom.
“The Mom’s Meals team was easy to work with, knowledgeable and always so responsive. They care about people and truly wanted to help. It was personal for them like it was for me.”
When Lindbloom was ready for a career change, fate would have it that an opportunity at Mom’s Meals was available as program manager of care navigation.
Mom’s Meals care navigators help connect New Yorkers to whole-person support
Lindbloom brought her experiences and focus to her new role at Mom’s Meals in mid 2026, created to support eligible New Yorkers. Mom’s Meals developed its care navigation team after multiple social care networks (SCNs) and counties identified a need for additional screening and navigation support. Through the state’s SCNs, the state is building a coordinated system for screening, navigation and service delivery.
She shares that it is a goal in New York that all New York Medicaid members can be screened for unmet health-related social needs (HRSN). Members may then receive navigation to existing federal, state and local resources, while eligible Medicaid managed care members may also be referred to enhanced services.
The screening supports New York’s Medicaid Section 1115 demonstration waiver and its goal of advancing health equity by connecting members with enhanced services that address HRSN. Those services can respond to four broad areas: nutrition, housing, transportation and care management.
How the care navigation process works:
- Connect
A member may be referred by a SCN, healthcare or community organization or may contact Mom’s Meals directly.
- Screen
A care navigator speaks directly with the member to identify what their HRSN needs are. In New York, there are four enhanced services that address HRSN needs: nutrition, housing, transportation or care management.
- Assess
If the screening identifies a need, the care navigator gathers information about Medicaid coverage, enhanced population status and any required clinical criteria, such as a chronic health condition.
- Refer
The navigator explains available options, makes referrals and honors member choice, sending members to participating organizations that can provide the appropriate services such as medically tailored meals, rental assistance, emergency shelter services and transportation service with approval from the managed care plan.
- Follow up
The navigator confirms whether services were received that they were eligible for, helps address barriers and reassesses the member if new needs arise or if additional referrals are needed.
Care navigation in action
As an example from a nutrition standpoint, depending on need and eligibility, support may include medically tailored home-delivered meals, nutrition counseling and education or produce and pantry boxes. If a member does not qualify for enhanced services, care navigators can still connect the person to resources such as SNAP, WIC or a local food pantry that does not require managed Medicare or Medicaid.
Additional support may be as simple as helping complete an application or as hands-on as joining a three-way call to schedule a medical appointment. For people without reliable phone or email access, or who are unsure what to ask for, those steps can be the difference between knowing a resource exists and receiving it.
Nutrition plays an important role in health, but it does not exist in isolation. A person may also need safe housing, reliable transportation to appointments or help coordinating care. A member’s situation can change quickly, too. For example, someone who first needs food and transportation support may later receive an eviction notice and need housing assistance.
“A person can’t be healthy if they’re not getting quality nutrition,” explains Lindbloom. “They also can’t be healthy if they can’t get to their doctor appointments or they’re living in an apartment with mold problems and needs asthma remediation services. It takes all those services to improve health outcomes.”
That’s why follow up is essential. Care navigators stay connected with each member, checking whether their referrals led to the services needed and pivoting to help members when circumstances change or additional support is required. The goal is not only to make the referral, but to connect the dots with the services to bring it all full circle and help close the loop.
Building trust, one connection at a time
The Mom’s Meals care navigation team has completed extensive network-specific, cultural competency, trauma-informed and other required trainings to prepare for their roles. That foundation helps navigators meet members where they are with respect, understanding the complexity of each situation and responding with appropriate next steps.
“A connection to each member matters as much as the task completed. We're creating a relationships and trust. Those connections help people have hope and a path to a better quality of life," shares Amira Lindbloom, program manager of care navigation at Mom’s Meals.
As the Mom’s Meals care navigation program grows in New York, so does the opportunity to help people move through complex systems and reach services that can support better health. Each referral, screening and follow up is one step toward more coordinated person-centered care for some of the most vulnerable populations.
“The more people we can help navigate these systems and get assistance, the better the health outcomes, Lindbloom said. “We’re happy to be part of those outcomes.”
