How Can We Help Primary Care Providers and their Patients?
Our outreach program is intended to extend the reach of your services by supporting your patients in achieving their health goals. Our team can provide health education, coaching and connection to social services and programs, as well as facilitate home care and provide caregiver assistance and support. Our team will also assist inpatient care coordinators with discharge planning if your patient is hospitalized. Our goal is to facilitate transitions of care throughout our system by providing the link between the community and the acute-care phases of care for better communication of patients' goals and needs, while providing quality care.
Who Should I Refer to the Community Care Management Team?
- Patients with multiple inpatient hospitalizations
- Patients you believe are high risk for declining health or hospital readmission
- Patients with complex chronic medical conditions (congestive heart failure, diabetes, COPD, pneumonia, behavioral health or substance use disorders)
- Patients who require complex care but have little or no family or caregiver support
- Patients with poor adherence to their medical plan of care
- Patients with complex social needs
- Patients who may require behavioral health services
- Patients who may use emergency department services instead of the appropriate level of care
- Patients who may benefit from additional health education
ICP Community Care Management Program Disclaimer:
Not all patients of the ICP physician member network are eligible for care management services. Please consult your ICP primary care physician for eligibility requirements into the program.