Intensive Care Management
Support for Members with Chronic Conditions
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.
How ICM works
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).
To refer members to ICM, call 1.800.440.5071 x2024, or fax a completed ICM Referral Form to 866.361.7242.
Elements of ICM Care Coordination
Nurse Managed Services
Appointment management services:
- Assistance with transportation needs
- Help finding in-network specialists
Patient coaching services:
- Support with treatment plan progress and medication management
- Reduce ED overuse and re-hospitalizations
- Evidence-based coaching
- Providing health education materials
- How to use health benefits
Community Support 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:
- Housing, food, and clothing assistance
- Childcare and parenting support
- Disability services and other related services
- Domestic violence support and legal services
- Employment services
- Educational and youth programs
- And more
If you have patients that would benefit from the additional support provided by ICM, call 1.800.440.5071 x2024, or fax a completed ICM Referral Form to 866.361.7242.
Care Management Programs
Healthy Airways
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.
Healthy Beginnings
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 moreThe Neonatal Intensive Care Unit (NICU) Program
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.
Healthy Living with Diabetes
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.
Living Well with Sickle Cell
Our nurses are here to help members who have Sickle Cell Disease and their families improve and maintain their health. We can assist members with getting to their appointments and making referrals to community resources. We coach members on the importance of having a Sickle Cell Action Plan, knowing when to follow the action plan, and knowing what to do if symptoms do not get better. Our nurses will work with you and the member to reinforce your treatment plan. We can also support members and their families when transitioning to adult clinics.
To refer your patients to this program call 1.800.440.5071 x2024, or fax a completed ICM Referral Form to 866.361.7242.
Other Chronic Conditions
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.
