Community Care Teams: An Overview of State Approaches

Brief
Key Questions Answered
  • How do I develop, implement, and spread care management models that use Community Care Teams (CCTs) to support primary care providers in delivering patient-centered care?
Key Themes and Takeaways

This resource provides information about CCTs, including an overview of core program features, governance structures, financing, and health informatics. It describes examples from several states, most extensively those in North Carolina and Vermont.

  • The goal of the CCTs is to support primary care providers in delivering quality-driven, cost-effective, and culturally appropriate patient-centered care.
  • The composition of CCTs can vary greatly depending on state staffing requirements and available community resources. They can include primary care physicians, nurses, pharmacists, behavioral health care providers, social workers, and non-clinical service providers.
  • States have established a variety of governance models to oversee the design, implementation, and administration of CCTs. Key elements include legislative, regulatory, or executive authority; operational oversight; stakeholder engagement processes; patient identification methodologies; and workforce staffing.
  • To realize the potential benefits of CCTs, adequate financing is essential. The predominant method of reimbursement for CCT services is through a per-member, per-month rate.
  • States that have implemented CCTs need to consider certification, training, and transitions of work.
  • There is growing interest in assessments of impacts on health care cost and quality within the context of broader health reform activities, and the ability to measure the effect of CCTs at a more detailed level is under development.
Population Addressed
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Expert Opinion
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