The health care system can be very complicated, particularly for patients with many health issues and related concerns. Many are receiving their care from their primary care physician and specialists, community providers and sometimes, hospital and rehabilitation facilities.

The Integrated Care Management Program (iCMP) is designed to reduce complication by supporting patients on their health care journey. Our iCMP nurses, social workers, and community health workers meet with patients and assess their health and social needs. Together, they identify barriers to good health and create a plan to address them. For some patients, the problems may be related to financial instability, difficulty managing personal care, or substance use. For others, it may be difficulty understanding their medical condition, social isolation or how to take their medication.

Our interdisciplinary team has the skills and experience to help patients improve their health and well-being. Our nurses teach patients about their medical issues and consider options for better health outcomes. Meanwhile, our social workers provide guidance on the social and emotional concerns related to health issues. They draw on the skills of our community resources specialists to connect patients to community services and to help them learn how to navigate the complex medical system. Similarly, our pharmacist simplifies and explains medication plans.

The iCMP team includes:

Nurse Care Coordinator

Provides coordination of care with primary care physicians and specialists

Assists with the transition of care from hospital to home

Offers education on health issues

Is a licensed, registered nurse with training in care coordination

Social Work Care Coordinator

Provides support for patients experiencing personal or family stress, serious mental health issues and substance use concerns

Assists with referrals to mental health and social service providers

Coordinates care between primary care physicians and mental health and social service providers

Is licensed with training in care coordination


Provides education on medications and tools to aid in taking medications properly

Reviews complex medication plans to address side effects, dosing and reduce pill burden

Assists with complex prior authorizations, access and affordability concerns

Is a licensed PharmD

Community Resource Specialist

Identifies barriers to care and resources to help overcome them

Researches program and services in the community including, but are not limited to, housing assistance; legal, financial and insurance resources; transportation, and nutrition, like Meals on Wheels and local food pantries

Provides health education materials and support in advocating for services

Community Health Work Care Coordinator

Identifies barriers to care and resources to help overcome them

Provides information on health and social services and helps apply for services

Trains on self-advocacy skills

Educates on self-management of chronic illness and medication adherence