The Integrated Communities Care Management Learning Collaborative is a health service area-level rapid cycle quality improvement initiative with the goal of improving cross-organization care coordination and care management. Teams from most Blueprint communities participate in a learning collaborative, then use the Integrated Communities Care Management tools to implement the process in their communities. This initiative is 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 individuals with complex needs.
The 2020 Evaluation of the Integrated Communities Care Management Learning Collaborative is available.
See Integrated Communities Care Management In Action
Integrated Communities Care Management Toolkit
The Integrated Communities Care Management Learning Collaborative toolkit offers tools, workflows and processes for improving cross-organization coordination and integration. The tools are organized in the order they are likely to be used in the process of collaboratively planning an individual's care. Each link below will download a PDF.
- Identify people with complex needs
Introduction and stratification tool
Workflow - Recruit people for cross-organization care management
Introduction and workflow
Sample recruitment letter
Sample recruitment script
Sample group release
Sample team release - Narrated guide: using tools to document a person's story, goals and care team
Introduction and workflow
Narrated guide for using suggested tools
Backwards planning user guide
Backwards planning game board
Camden cards with pictures
Camden cards with prompts
Eco map instructions
Blank eco map
Completed eco map - Review person's health history
Introduction
Chart review tool
Health history review tool - Conduct root cause analysis
Introduction
Root cause analysis worksheet
Lauran Hardin's root cause analysis presentation - Convene first care team conference
Introduction
Why care conferences are important
Sample agenda
6 tips for effective meetings
Tips for including PCP in care conference - Identify person's lead care coordinator
Care coordinator framework
How to determine the lead care coordinator
Lead care coordinator duties and responsibilites - Develop, implement, and monitor shared care plan
Introduction/fact sheet and workflow
Shared care plan, example A
Shared care plan, example B
Shared care plan, example C - Convene subsequent conferences
Family centered approach to care conferences