Integrated Communities Care Management Model



Vermont's Integrated Communities Care Management Learning Collaborative (ICCMLC) trains communities in Vermont to implement the Integrated Care Management (ICM) Model to improve care for complex patients. ICM targets patients through the Camden Coalition's hotspotting technique, which identifies geographic areas with high proportions of residents with complex needs. Once patients have been identified and enrolled, they are assigned a Lead Care Coordinator (LCC) who guides joint care planning and helps the patient 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 transportation.

Partner Organizations

  • Vermont Blueprint for Health
  • The Green Mountain Care Board
  • Vermont Program for Quality in Health Care, Inc. 

Target Population

Individuals with complex care needs 

Care Team

Lead Care Coordinator


2014 - present

Results/ Studies

Overview and results (2017)

Evaluation report (2017)


CMS State Innovation Model Grant


Program website