Community Care Teams
Eight Teams Selected as Community Care Team ProvidersFollowing a selection process in August, Maine Quality Counts and the Maine PCMH Pilot selected eight health organizations which will serve as Community Care Team (CCT) providers:
Project Update - February 2012In November 2010, Maine was selected as one of eight states to participate in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration, Medicare’s major medical home initiative. Medicare has joined private purchasers and Medicaid as a payer in the Maine Patient Centered Medical Home (PCMH) Pilot, beginning in January 2012. The Maine PCMH Pilot began in 2010, with participation by 26 primary care practices and major payers including Anthem BCBS, Aetna, Harvard Pilgrim Health Care and MaineCare. Community Care Team (CCTs) are considered a key strategy for improving care and reducing avoidable costs for patients in the Pilot and MAPCP demo, especially those with complex or chronic conditions. CCTs will coordinate and connect patients to additional healthcare and community resources in order to support their health improvement goals, achieve better health outcomes and reduce avoidable costs. Read more...
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CCT Strategies & FunctionsMany primary care practices could benefit from strategies and functions employed as part of the CCT model. Some of the most promising of these include:
-Nurse care management; -Case/panel management (screening, patient identification, scheduling appointments, referrals ); -Behavioral health (brief intervention, cognitive behavioral therapy, motivational interviewing, and referral); -Substance abuse services (screening, brief treatment and referral ); -Psychiatric prescribing and pharmacy consultation for providers; -Medication review and reconciliation; -Oral health services; -Health coaching for nutrition, physical activity, tobacco cessation, diabetes, asthma, other chronic disease; -Chronic disease self-management education and skill-building, such as linking to Living Well programs; -Other non-clinical services to actively connect patients to community organizations that offer supports for self-management and healthy living, transportation assistance, housing, literacy, economic and other assistance to meet basic needs
Many feel that, based on the long-term success of programs in other states, this model represents the beginning of a shift in payment systems, and it is expected that it will spread beyond the 26 practices that are participating this year. In February 2012, a call for applications was issued to expand to 20 more adult PCMH practice, and many of those applicants will also be eligible to become MaineCare “Health Homes” which is a single-payer model that combines a medical home and a CCT.
Community Care Team Goals & Services
The primary goal of the CCT is to provide support for the most complex, high risk, high need, and/or high-cost patients served by ME PCMH Pilot. CCTs and Pilot practices will work together to identify and serve high risk/high need patients in the practice regardless of age, health status or insurance coverage status. The criteria to determine high risk/high need patients will be defined by the CCT in collaboration with their PCMH Pilot practices, and reassessed on an ongoing basis based on the population served. |