Effective Community Care Teams: State Snapshots

Mar 10, 2019

Community Care Teams (CCTs) are an integral piece of healthcare transformation and are helping to bridge gaps at the local level. These locally-based care coordination team employed to address a patient’s complex needs across providers, settings and systems of care. Teams help to integrate essential needs and community-based resources into primary care – with a goal of delivering patient-centered care that is quality-driven, cost-effective and culturally appropriate.

While their composition can vary greatly, Community Care Teams are generally connected to patient-centered medical homes to assess individuals’ needs, provide multidisciplinary care and coordinate community-based support services.

Core Features of a Community Care Team

  • CCTs are multidisciplinary teams that often include primary care physicians, nurses, pharmacists, behavioral health providers, social workers, community-based service providers and others.
  • CCTs coordinate critical services like chronic disease management, medication assistance, essential resource connections and more.
  • Team members routinely connect patients with relevant community-based resources, emphasizing face-to-face contact. CCTs often focus on transitions in care, particularly between hospital and home.
  • The work of CCTs often spurs enhanced reimbursement, predominantly through capitated or per-member/per-month rates.

Find state-based examples of effective community care teams in the overview below – along with additional case studies and insight in the full Overview of State Approaches report from the Center for Health Care Strategies (CHCS) and State Health Access Data Assistance Center (SHADAC).


Download the Community Care Team Overview

How are you seeing these relationships and connections improving in your community? Let us know in the comment section below!


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