Assisting Communities in Providing Better Coordinated Care

The Integrated Communities Care Management Learning Collaborative

Project Summary

(click here for the complete Evaluation Report)

Persons with complex health conditions and psycho-social needs may benefit from a wide variety of medical and social services from many different providers. It is essential that the care provided to these persons is not “fragmented,” with different agencies providing care in multiple locations without communicating adequately with each other about that person’s history and plan of care. Fragmentation of care can cause confusion and challenges in following care plans; over-treatment and uncontrolled costs through unnecessary tests or duplication of services; or under-treatment and poor outcomes based on incomplete information or misidentification of the person’s primary health determinants.

In many communities throughout the country an Integrated Care Management (ICM) model has been implemented to make health care more person-directed, progressive, and non-episodic. The ICM model supports joint care planning with the person and his or her diverse providers across multiple organizations, with the goal of identifying and preventing the underlying reasons for poor health outcomes. Integral to ICM is the recognition that, in the majority of cases, a person’s primary health determinants are related to social, environmental, and behavioral factors. In fact, recent data suggest that only 20% of health outcomes are determined by clinical health care. [1]

Once a person’s underlying reasons for poor health outcomes have been identified, a Lead Care Coordinator (LCC) guides joint care planning and helps the person define and work towards personal, social, emotional, and health-related goals. In addition to clinical support, the LCC helps coordinate essential community services based on identified needs, which may include housing, food insecurity, substance abuse, mental health, violence, economic issues, and/or transportation, among others.

The ICM model should produce these positive effects:

  • care is less fragmented
  • persons can access timely, appropriate, high-quality care
  • persons can engage more fully in their own care
  • communication between providers is better coordinated, improving continuity of care and lowering cost
  • systems and tools efficiently share and apply information about a person’s care among their providers

In 2014, the Integrated Communities Care Management Learning Collaborative (ICCMLC) began helping communities implement ICM in Vermont. The work is funded through a $45 million State Innovation Models (SIM) Testing grant from the federal Center for Medicare and through a collaborative effort of Vermont Program for Quality in Health Care (VPQHC), the Green Mountain Care Board, the Department of Vermont Health Access including the Vermont Blueprint for Health. Since the inception of the Learning Collaborative, the program has increased from 3 initial volunteer communities to 11 communities across the state. Significant connections have been established among a broad group of stakeholders including, but not limited to, hospitals, community health teams, social services, mental health services, home health services, primary care practices, housing agencies, peer and advocacy organizations, and agencies on aging, with the goal of better coordinating care for identified persons with complex health conditions. This truly integrated community approach will provide lasting benefits to these communities.

The ICCMLC supports participating communities to improve cross-organizational care management by providing opportunities to share ideas with national experts, community leaders, front-line care management staff, state policymakers, and quality improvement facilitators. Some of the excellent presentations available to learning collaborative participants over the past year included:

“Identifying and Engaging Individuals in Cross-Organizational Care”

Kelly Craig, MSW, Program Director for Care Management Initiatives with the Camden Coalition of Healthcare Providers guided participants in how to use data to identify high utilizers. She also advised the group in effective ways of conducting initial outreach to encourage participation. The Camden Coalition of Healthcare Providers is a coalition of hospitals, primary care providers, and community representatives that has been a leader in the targeted use of data and focus on human-centered, coordinated care to improve patient care and reduce costs.

“Preparing to Deliver Integrated Care Management Across Organizations”

Lauran Hardin MSN, RN-BC, CNL, Director of Complex Care at Mercy Health provided training in completing a Root Cause Analysis (RCA), including a focused chart review guided in part by the enrollees’ self-identified areas of greatest importance. The goal of doing the RCA is to find patterns (systematic, behavioral, medical, or social) in the clinical record that may be contributing to the enrollees’ high utilization, and that might not have been considered adequately by the team before.

"Implementing Integrated Care Management Across Organizations: Using Shared Care Plans and Cross- Organizational Care Conferences”

Jeanne W. McAllister, BSN, MS, MHA, Associate Research Professor of Pediatrics, Indiana University School of Medicine and Jill S. Rinehart, MD, FAAP, of Hagan, Rinehart & Connolly Pediatrics, PLLC provided training in forming inter-agency teams around people with a risk of high utilization.They also discussed the development and use of Shared Care Plans and how using care conferences promoted the goals agreed upon by each member of the team.

Recommendations and Next Steps

With SIM funding ending in 2016, the ICCMLC leadership’s focus is on ensuring the long-term sustainability of the ICM model in Vermont.While VPQHC and the ICCMLC will continue to support new providers and communities in implementing ICM inVermont, there is a strong focus on skill development within existing communities, to ensure they have the internal supports needed to maintain and expand their collaborative work.VPQHC will also assist in the overall evaluation of the success of the ICCMLC, by continuing to track patient and provider experience, as well as health outcomes.


[1] Bradley EH,Taylor LA, Rogan E. American Health Care: Spending More, Getting Less. Vermont Blueprint Annual Meeting, South Burlington,VT. 12 April 2016. Keynote Address.

(click here for the complete Evaluation Report)