Care Coordination for Adults: The Interactive Community-Based Model

What is the Interactive Community-Based Model?

The Interactive Community-Based Model (ICBM), originally funded in 1992 by a grant from the U.S. Rehabilitation Services Administration, was developed to help Alabamians with traumatic brain injury (TBI) access community resources that would enhance their opportunities to work.

The ICBM is an interactive, criterion-based model of vocational rehabilitation for people with TBI. It is a five-phase model designed to address employability, independence, and community reintegration for TBI survivors. The model empowers the TBI consumer and family through active participation in individualized assessment, goal setting, and performance evaluation. There are a number of forms used with each phase of the ICBM . They are used to provide structure, monitor progress, identify and address functional limitations, develop individualized goals and plans, and promote family involvement.

What is the goal of the ICBM ?

The ultimate goal of the ICBM is improving the consumer’s readiness for services that lead to employability. Participation in the ICBM enables the consumer to develop a realistic view of vocational potential to meet the ultimate goal of an employment outcome. The ICBM provides flexibility and support that are needed during the early recovery process. It allows the consumer to move among the phases as necessary, i.e., among the home, community, job site, and vocational components. The program begins with independent living, behavior, and prevocational skills training which take place in the home.

Who qualifies?

This program is designed primarily for individuals who:

  • have sustained a traumatic brain injury as a result of a neurotrauma
  • are less than two years post-injury
  • are not appropriate for traditional vocational rehabilitation services at the time of referral
  • can benefit from a cognitive and behavioral rehabilitation program

How are referrals to the ICBM made?

Referrals to the ICBM are made by traditional vocational rehabilitation referral sources. They come from an existing network of contacts within the rehabilitation community. These contacts include acute health care facilities, the Head Injury Registry coordinator, Head Injury Foundation liaisons, rehabilitation counselors, Independent Living Center staff, other care providers, educational professionals, family members, and interested individuals.

The vocational rehabilitation counselor receives a referral and makes an initial contact with the individual and family. The counselor may determine that the Interactive Community-Based Model ( ICBM ) may be appropriate. If the TBI consumer chooses to participate in the ICBM, the care coordinator initiates services.

There are situations in which other agencies or organizations have primary responsibility for providing services or programs for the individual. When this occurs, the care coordinator assumes a supportive role and works cooperatively with the other agency/organization in providing services.

Is the program effective?

The overall impact of the ICBM has been significant. The ICBM has:

  • reduced the cost of post-acute care services for individuals with TBI;
  • reduced the time of referral to vocational rehabilitation by more than two-thirds of the national average; and
  • contributed to the average income of consumers who participate in the ICBM being 15 percent higher than those who do not.

ICBM Phases

There are five phases to the ICBM . The length of time in each phase is dependent on the extent of neurological and psychological recovery as well as many other factors, including the availability of services in the consumer’s home area. The five ICBM phases are:

  • Phase I: Home-Based Rehabilitation
  • Phase II: Community-Based Rehabilitation
  • Phase III: Vocational Rehabilitation Evaluation
  • Phase IV: Vocational Rehabilitation Services
  • Phase V: Employment

Phase I: Home-Based Rehabilitation

Phase I-A: Assessment and Evaluation

Phase I-A is a home-based needs assessment and evaluation. The care coordinator provides a program overview, gathers basic information, and explores consumer and family expectations.

Phase I-B: Home-Based Intervention

Phase I-B is the implementation of a behavioral rehabilitation program. The consumer develops or refines the home-based skills that meet goals established in the Individualized Written Care Plan. When each goal in the home-based plan is met consistently, the participant may then proceed to Phase II-A.

Phase II: Community-Based Rehabilitation

Phase II-A: Community-Based Intervention

Phase II-A is participation in community-based activities. The care coordinator facilitates the consumer’s participation in a community-based program (e.g., a community-based rehabilitation program, independent living center, church, school, or volunteer activities).

Phase II-B: Transition to Vocational Rehabilitation

Phase II-B is the transition to a traditional vocational rehabilitation program. The vocational rehabilitation counselor becomes the primary service coordinator, and care coordinator services are discontinued. If the consumer is not ready for traditional vocational rehabilitation services, a plan is developed to increase the maximum level of community reintegration, and care coordinator services are terminated.

Phase III: Vocational Rehabilitation Evaluation

Phase III is formal vocational rehabilitation evaluation and assessment. The vocational rehabilitation counselor employs traditional vocational rehabilitation case management for the remainder of the rehabilitation program.

Phase IV: Vocational Rehabilitation Services

Phase IV includes development and implementation of the Individualized Plan for Employment (IPE). The plan is based on consumer choice and information obtained in Phases II and III. The plan may include work adjustment, career planning, on-the-job training, vocational/technical training, supported employment, and job placement activities.

Phase V: Employment

Phase V marks the level of employment that represents the consumer's current maximum capacity for work. The ultimate objective of Phase V is a successful closure with the consumer working in the most appropriate environment.

ICBM Brochure