Community Care Management Program

Community Care Management ProgramICP’s Community Care Management Program, which improves care for patients with chronic health issues who are at high risk for hospitalization and complications from their illnesses, represents a major step in coordinating patient care and managing population health.

The ICP Community Care Management Team includes 24 nurses, 10 social workers and 2 pharmacists – all nationally certified in managing chronic diseases. This collaborative team helps patients with chronic illnesses -- especially those not engaged in their own care -- patient transitions from the acute-care setting to the community and with support to providers whose patients could benefit from community resources.


Who We Are

ICP’s Community Care Management Team of registered nurses and social workers focuses on our patients’ well-being and health goals. Our team is dedicated to improving the patient experience and patient satisfaction by extending the traditional reach of providers to the patient’s home and to the community, where patients are most comfortable receiving care. Our team is nationally certified in Chronic Disease Care Management, a growing specialty of Case Management.

How Do We Help Primary Care Providers and Their Patients?

Our outreach program expands your services by helping patients meet their health goals. Our team provides health education, coaching and connection to social services and programs and socio-behavioral services. We also facilitate home care and provide caregiver assistance and support. If your patient is hospitalized, our team will assist inpatient care coordinators with discharge planning. We’re the link between the community and acute patient care phases. By defining patients’ goals and needs, our team facilitates transitions of care throughout our health care system.

Patient Populations We Serve

  • Patients identified as high risk for declining health or hospital readmission.
  • Patients with complex chronic medical conditions (congestive heart failure, diabetes, COPD, pneumonia, depression).
  • Patients with multiple health care providers.
  • 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 benefit from additional health education or coaching.
  • Patients who may require behavioral health services.
  • Patients who may use emergency department services instead of the appropriate level of care.

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.

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