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    ICM Model

    ICM Scope and Application

    The Integrated Care Model (ICM) is a patient centered, evidence-based model with care coordinated and supported across sectors and time. ICM training and model replication is occurring within acute, ambulatory, home health, palliative and hospice settings nationwide. Approximately 7,650 providers have been certified as Trainers in ICM and are replicating the care delivery model, with varying degrees of model fidelity, in 49 US states and in one Canadian province.

    ICM Theory and Evidence-Based Foundation

    An accepted guide for primary care practices working with patients with chronic conditions is The Chronic Care Model as described by Dr. Edward Wagner (1998). This model was developed to redesign primary care delivery, with additional focus areas identified to best support long-term management in the home and community settings. The ICM model is an adaption of Wagner’s model with the aim of solidifying the partnership between the physician, the practice team in the community and the patient. Over time, ICM evolved to incorporate additional new evidence, including a greater focus on patient empowerment, person-centered care, health literacy, and best practices to support care transitions.

    ICM is founded on the most efficacious practices, interventions and tools in the most recent literature. The goal of this model is to take the “best of the best” and maximize patient support where the patient faces daily challenges – the home. The ICM model tenets include evidence-based, patient-centered practices in clinical management, self-management support, care transitions and care coordination. This evidence is derived from industry leaders such as Dr. Edward Wagner, Dr. William Miller, Dr. Stephen Rollnick and Dr. Eric Coleman, from extensive policy research, and from best practices from the fields of adult education and social psychology.

    ICM Training to Provide Person-Centered, Evidence-Based, Coordinated Care

    ICM addresses changing both provider behavior and patient behavior in order to realize positive health outcomes. The ICM certification course was designed to equip providers with the competencies identified by Bodenheimer and Lorig for optimal self-management support (Bodenheimer, 2002, Lorig, 1999). Specifically there are six competencies that these researchers believe are most effective at improving care delivery:

    1. Person-centered approaches that build trust, shared understanding and strong provider-patient relationships
    2. Individualized assessment of patient needs, values and preferences
    3. Collaborative goal setting and action planning
    4. Skill building and problem solving
    5. Linkage to community resources and programs
    6. Repeated follow-up contacts
    Updated ICM training has core components of the best practices for care transitions as identified by Dr. Coleman and Dr. Mary Naylor. Specifically the components that have been added to ICM training are:
    1. Areas of patient focus and support needed during a patient transition from hospital to home: knowledge and actions for condition exacerbation (red flags), medication management, physician follow-up visits and initiation of a personal health record (PHR).
    2. Identification of gaps in current care related to management of high risk chronically ill patients, palliative care, and advanced illness management.
    ICM model training facilitates meeting the intent of the new CMS proposed conditions of participation to ensure a:
    • Continuous, integrated care process across all aspects of home health services
    • Patient-centered, interdisciplinary approach that recognizes the contributions of various skilled professionals
    • An evidence and outcome-based approach to patient care that can be understood by the patient and caregivers and incorporates the shared decision making model
    Lastly, ICM training includes a focus on the case management role and process with a strong emphasis on best practices in communication and coordination with the care team. ICM training culminates in assisting clinicians to clearly articulate the value of these competencies to key stakeholders including patients and families.