Intensive Care Management (ICM) provides comprehensive care coordination services for members with multi-morbid conditions. These services help to reduce missed appointments, reduce unnecessary trips to the Emergency Department (ED), and improve member self-care between provider visits. ICM nurses work directly with providers and patients to manage chronic and multi-morbid conditions through a person-centered plan of care. By meeting members “where they’re at,” ICM provides focused care coordination resulting in improved patient participation for better health.
Step 1: ICM nurses outreach to identified or referred members to offer the Care Management program.
Step 2: A holistic ICM Assessment is conducted that evaluates a member’s medical, behavioral, and social determinants of health, self-care ability, screenings, and more. A person-centered plan is then developed with the member using motivational interviewing. The plan is then shared with the member's provider.
Step 3: ICM nurses work with providers, Community Health Workers (CHWs), dietitians and other agencies to help members access the care and programs they need to achieve their health goals.
Step 4: ICM nurses reinforce the provider’s plan of care for the member and provide teach-back learning and education to improve self-reliance.
Step 5: Once care plan goals are achieved, the member can continue to outreach to ICM services for changes in their health status or condition(s).
Appointment management services:
Patient coaching services:
Community Health Workers (CHWs) are front line workers who empower families to improve their health and stabilize their living situations by helping them access available community resources. They work closely with ICM Care Managers to help members navigate the healthcare system and manage their chronic conditions in culturally relevant ways.
CHWs provide the following patient assessment and referral services:
Our nurses work with members who have asthma. We coach members on the importance of having an Asthma Action Plan, knowing when to follow the action plan, identifying and controlling asthma triggers, and knowing what to do if symptoms do not get better. We will also answer questions about different medications and when to use them.
This program is for those who are pregnant or have recently given birth. Nurses work with pregnant members, their providers, and their families to support the member with understanding the provider plan of treatment to help improve health outcomes for the pregnant individual and the infant. They also provide support for education on topics including newborn care, safety, and breastfeeding.learn more
This program is for babies who are born early, or who need special care after birth. Our nurses work with families, hospital staff and providers to help support these special babies and their development.
Our nurses work with members who have diabetes and their providers to develop a plan of care. We also help members figure out the best ways to manage their diabetes.
Our nurses help members who have Sickle Cell Disease and their families find the services they need to improve and maintain their health.
Our nurses help members who have any other chronic or complex health issues. We help members get the care and services that they need, when they need them.
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