Community Care Management Program

Who We Are

ICP's Community Care Management Team is made up of nurses and social workers focused on the patient's well-being and on helping the patient meet his or her health goals. Our team, in partnership with integrated primary care behavioral health clinicians, is designed and 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.

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

Our Community Care-Manager Competencies:

  • Coordination of patient transitions from the hospital or skilled-nursing facility
  • Chronic disease education and management
  • Medication review and education
  • Comprehensive patient assessments
  • Motivational interviewing
  • Assistance with end-of-life care and planning
  • Assistance with non-adherence behavior management
  • Cognitive and geriatric risk assessments
  • Depression and anxiety screening
  • Legal and financial assistance
  • Knowledge of state and federal entitlement programs and application assistance
  • Behavioral health and substance use services
  • Caregiver support and resources, including respite care
  • Coordination of home care and community social services

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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