Integrated Care Management (ICM) model goals around evidence-based care
- Apply evidence-based principles and condition specific guidelines.
- Application of guidelines fit with patient preferences.
- Develop clinical, educational, and psycho-social provider competencies related to the provision of self-management support and health literate care delivery. Competencies equip providers to serve as valued members of the prepared, proactive care team.
- Demonstrate evidence-based leadership. Leadership efforts facilitate hardwiring of best practices and promote transformational change.
This ICM model principle addresses both provider and patient behavior in order to develop the competencies necessary to realize positive health outcomes. Evidence based practices and tools include current guideline level care for disease and condition management, augmented with best practices and principles designed to:
Employ clinical best practices:
- Comprehensively assessing patient needs and identifying common barriers using validated tools paired with clinical expertise.
- Delivering health literate care through a universal precaution approach encompassing accessible and actionable tools: award-winning stoplight forms and a personal health record (PHR).
- Providing interventions based on clinical evidence to promote physical, emotional and psycho-social well-being to the extent that is individually practicable.
Employ self-management and behavior change best practices:
- Teaching is interactive and guided by the principles of self-guided learning, problem solving and learning by “doing.”
- Measuring confidence with condition self-management and enhancing patient self-management skill acquisition using methods such as teach back, patient SBAR, and tools including confidence and importance rulers.
- Structuring mastery experiences to promote high patient self-efficacy with condition management.
Employ principles that foster transformational change:
- Developing a change vision and reducing barriers for change.
- Using reliable and timely feedback to track performance for continual improvement.
- Hardwiring excellence by celebrating short term wins and sharing positive stories, rounding for outcomes via multidisciplinary care conferences and attending bi-weekly huddles.
- Creating a culture of learning that values teams and utilizing behavior change principles with staff.