Community care teams (CCTs) — also called community health teams or care networks — are locally based, multi-disciplinary teams that manage patients’ complex illnesses across providers, settings, and systems of care.* CCTs emphasize in-person contact with patients and support the delivery of quality-driven, cost-effective, and culturally appropriate patient-centered care by coordinating patients’ medical and social service needs.
This resource paper provides information on CCT programs in several states and includes:
- An overview of core program features;
- Key elements of governance models;
- Approaches to financing and reimbursement;
- Considerations for workforce requirements; and
- Examples of health informatics models to support CCT initiatives.
The paper was produced by CHCS and the State Health Access Data Assistance Center (SHADAC) with support from the Center for Medicare & Medicaid Innovation (the Innovation Center). CHCS and SHADAC are part of a team led by NORC at the University of Chicago that serves as the State Innovation Model Resource Support Contractor. CHCS, SHADAC, and other technical assistance partners support states and the Innovation Center in designing and testing multi-payer health system transformation approaches.
* M. Takash and J. Buxbaum. Care Management for Medicaid Enrollees through Community Health Teams. The Commonwealth Fund, May 2013.