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Integrated Communities Care Management

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.

  1. Identify people with complex needs
    Introduction and stratification tool
  2. Recruit people for cross-organization care management
    Introduction and workflow
    Sample recruitment letter
    Sample recruitment script
    Sample group release
    Sample team release
  3. 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
  4. Review person's health history
    Chart review tool
    Health history review tool
  5. Conduct root cause analysis
    Root cause analysis worksheet
    Lauran Hardin's root cause analysis presentation
  6. Convene first care team conference
    Why care conferences are important
    Sample agenda
    6 tips for effective meetings
    Tips for including PCP in care conference
  7. Identify person's lead care coordinator
    Care coordinator framework
    How to determine the lead care coordinator
    Lead care coordinator duties and responsibilites
  8. 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
  9. Convene subsequent conferences
    Family centered approach to care conferences