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.

Factors contributing to this risk stratification and patient identification should include at least one or more of the following:

• frequent hospitalizations (two or more in past year)

• frequent visits to ED for urgent or emergent care (two or more in prior six months)

• high resource use (e.g. frequent provider visits, multiple pharmacy use)

• multiple comorbidities, including behavioral health and/or substance abuse

• complex medication management

• barriers to medication adherence

• poor health literacy

• high risk psychosocial status: inadequate social and /or financial support system

• advanced age, with frailty & risk for falls

• other high risk/ high need patients as identified by the practice or patients

Services that may be provided by the CCT (either directly or through contracting and referral arrangements) include:

• Medical assessments and complete community/social service needs assessments;

• Nurse care management (including patient visits prior to hospital discharge, in the primary care practice, group visits or at home);

• Case/panel management (screening, patient identification, scheduling appointments, referrals to care managers and other team members);

• Behavioral health (brief intervention, cognitive behavioral therapy, motivational interviewing, and referral);

• Substance abuse services (screening, brief treatment and referral );

• Psychiatric prescribing consultation for providers (provided by psychiatrist);

• Medication review and reconciliation (may be provided by pharmacists, pharmacy techs, or nurses);

• Pharmacy consultation for providers;

• Transitional care;

• 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

Services that the CHT will have a strong working relationship with and actively connect patients with include:

• Home health services;

• Substance abuse counseling;

• Intensive mental health services;

• Dental care; and

• Palliative care and hospice care.