Care Management
General care management processes and resources.
Assessment | Service Planning | Medical Terminology | Health Literacy and Self-Management | Ethics | Transitions
Care Management Manual Heading link
UIC College of Nursing has developed this manual to support Comprehensive Program care managers in delivering care to class members. The document addresses outreach, assessment, service planning, and ongoing implementation, monitoring, and documentation.
Additional webinars addressing specific aspects of care management are also available:
- Webinar: Communication & Collaboration: Effective Service Plan Implementation
Presented by UIC CON on August 6, 2020
Recorded webinar | Webinar transcript | Slides - Webinar: Post-Transition Care Management: Home Visits and Effective Documentation
Presented by UIC CON on September 3, 2020
Recorded webinar | Webinar transcript | Slides - Webinar: Building Independence: Supporting Self-Management
Presented by UIC CON on September 17, 2020
Recorded webinar |Webinar transcript| Slides - Webinar: Care Coordination of Complex Medical Conditions
Presented by UIC CON on February 18, 2022
Slides - Care Management CCMTP Orientation Module updated September 19, 2023 | Slides
Assessment Heading link
Comprehensive Program policy, P2.01 Assessment, states that each Class Member is entitled to an assessment to determine required supports and community-based services to safely transition. Agencies must use an approved assessment tool to conduct these assessments.
There are several required entry areas in the WebApp for assessment including: Class Member information, challenges, condition status which includes diagnoses, medication, and functional status, summary, and outcome. The process for entering this information in the WebApp is described in detail in the required Orientation Module, T2.1 Assessment, located in the Orientation Courses tab of the Colbert & Williams training website. Additional Training Materials are located in the UIC CON Training Archive.
Supporting Documents for Assessment (Completed for a fictional Class Member)
- 2.3 Facility Record Request
- 2.5 Transition Proceeding Notification
- 6.4 Neuropsychological Evaluation Referral Form
- 6.5 IDHS Consent Form
- 6.9 UIC ATU Intake
Additional resources:
- Assessment and Documentation of High Risk Health Conditions and Barriers Handout (Provided during Care Management Webinar 10/28/2021)
- Mini Mental Status Exam Handout (Provided during Care Management Webinar 11/2/2023)
Service Planning Heading link
Comprehensive Program policy, P3.01 Transition and Integration Planning, outlines the information needed to effectively develop a service plan and service planning goals.
Service Plans must be developed using the Comprehensive Program Service Plan tool in the WebApp. The process for entering this information in the WebApp is described in detail in the required Orientation Module, T3.1 Service Plan, located in the Orientation Courses tab of the Colbert & Williams training website.
The Comprehensive Program requires review of the Class Member’s service plan by the University of Illinois at Chicago College of Nursing (UIC CON) for quality. Policy P3.06, Service Plan Quality Review, outlines the components of a proficient service plan.
- Webinar: Best Practices in Service Planning
Presented by UIC CON on July 7, 2022
Recorded webinar | Slides
Supporting Documents for Service Plan (Completed for fictional Class Members)
Medical Terminology Heading link
- Common Medical Terminology handout
- Medical Terminology & Medical and Assistive Devices slides
- Medical Terminology 101
- IDPH Overview of Home Health, Home Services, and Home Nursing Services
- Webinar: Medical Records and Terminology
Presented by UIC CON on July 2, 2020
Recorded webinar | Webinar transcript| Slides
Health Literacy and Self-Management Heading link
- Health Literacy slides
- Question Builder (AHRQ): Assists with building a list of questions for an upcoming medical visit
- Webinar: Increasing Health Literacy
Presented by UIC CON on June 18, 2020
Recorded webinar | Webinar transcript |Slides - Webinar: Self- Management of High-Risk Health Barriers
Presented by UIC CON on November 11, 2021
Recorded webinar |Slides
Ethics Heading link
- Webinar: Ethics in Community Transitions
Presented by UIC CON on October 15, 2020
Recorded webinar | Webinar transcript| Slides
Transitions Heading link
- Reaching Transition Targets
Document created by IDHS September 2021