Rosie D.
Reforming the Mental Health System in Massachusetts

Step 3:  Intensive Care Coordination


Intensive Care Coordination (ICC) assists families and children locate, access, coordinate and monitor mental health, social services, educational and other services.  This is a vital step along the Pathway to Home-Based Services. When a child is determined to have serious emotional disturbance and needs or receives services from multiple providers or governmental agencies, s/he is entitled to receive intensive care coordination.  Intensive Care Coordination includes a comprehensive home-based assessment, a single care coordinator, a single treatment team, and a single treatment plan for all services.


Intensive Care Coordinator:  Every child who is determined to have SED and needs ICC is promptly assigned an intensive care coordinator.  The intensive care coordinator, sometimes called a care manager, will either be a licensed mental health professional or will provide care management under the supervision of a licensed mental health professional.  S/he will be trained in the wraparound process – a planning process involving the child and family that results in a unique set of community-based, individualized services to enable the child to succeed.


Responsibilities of the intensive care coordinator: The intensive care coordinator is responsible for overseeing and coordinating all home-based and other services for the child.  The coordinator is the single point of accountability for developing and implementing home-based services for the child.  The coordinator convenes and oversees a single, coordinated treatment team that works with the family to plan the home-based services.  The care manager works directly and with the child and the family, and prepares, monitors and reviews the child’s treatment plan.  The specific duties include:


·         identifying the members of the single treatment team;

·         identifying the strengths of the child and family, as well as any community supports;

·         collecting background information and plans from other agencies;

·         convening, coordinating, and communicating with the team;

·         preparing, monitoring, and modifying the child’s individual treatment plan, as directed by the team;

·         accessing the specific home-based and other services identified in the treatment plan;

·         working directly with the child and family;

·         collaborating with other caregivers on the child and family’s behalf; and

·         planning for aftercare or alternative supports when home-based services are no longer needed. 


For a detailed description of the role of the care manager, read the Feature on Care Managers.


For a detailed description of ICC, see the ICC Medical Necessity Criteria and the ICC Program Specifications.


Click here for Step 4, Comprehensive Home-Based Assessments

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