Care Management Toolkit

Integrated Communities Care Management Learning CollaborativeToolkit

The Integrated Communities Care Management Learning Collaborative (ICCMLC) is a health service area-level rapid cycle quality improvement initiative with the goal of improving cross-organization care coordination, care management, communication, and integration in communities state-wide. Learning collaborative teams are active in 11 communities and represent a partnership of the Blueprint for Health, Vermont’s Accountable Care Organizations, the Agency of Human Services, commercial insurance providers, community based social services organizations, and many others working together to improve outcomes for complex individuals. The collaborative is based on the Plan-Do-Study-Act (PDSA) quality improvement model, and features in-person learning sessions with national experts, webinars, implementation support, and testing of key interventions. The Integrated Communities Care Management Learning Collaborative toolkit highlights key tools, workflows and processes for improved cross-organization coordination and integration; and the tools can be adopted for use in various settings as needed.




Identify a Person's Goals Video


Identify a Lead Care Coordinator Video


Shared Care Conference Video

1.  Identify people with complex needs

2.  Recruit people for cross-organization care coordination

3.  Narrated guide: using tools to document a person's story, goals and care team

4.  Review person's health history

5.  Conduct root cause analysis

6.  Convene first care team conference

7.  Identify person's lead care coordinator

8.  Develop, implement, and monitor shared care plan

9.  Convene subsequent conferences