Community Care Teams: A Promising Strategy to Address Unmet Social Needs

Heflin K, Thomas-Henkel C
Publication Year: 2016
Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Population Focus: Complex care, Medicaid beneficiaries
Intervention Type: Staff design and care management
Type of Literature: Grey
link: https://www.chcs.org/community-care-teams-a-promising-strategy-to-address-unmet-social-needs/
Abstract

Social determinants of health, including income, employment status, and access to healthy food and transportation, account for as much as 40 % of individual health outcomes. Increasingly, states are recognizing the importance of interdisciplinary care teams and community linkages to address medical concerns as well as these social needs. These care teams can help achieve healthy outcomes, bend the cost curve, and improve patient satisfaction by extending care beyond the walls of a medical office. One specific model, community care teams (CCTs), is worth a closer look.

Insights Results

Overview of article

  • Social determinants of health, including income, employment status, and access to healthy food and transportation, account for as much as 40% of individual health outcomes. As a result, states are recognizing the importance of interdisciplinary care teams and community linkages to address medical concerns as well as these social needs
  • Community care teams (CCTs) are locally based, multi-disciplinary groups of care providers. In contrast to traditional care teams that focus solely on patients’ clinical needs, CCTs address medical issues and the social determinants of health. CCTs assist with health management, facilitate communication between patients and providers, assess social and non-clinical barriers to health, and connect patients to appropriate treatment and other needed resources
  • Over the past 10 years, a number of states have scaled and spread CCTs. For example, statewide initiatives are underway in Maine, North Carolina, and Vermont and they are beginning to show improvements in health outcomes

Results

  • Maine launched eight CCTs throughout the state in early 2012 as part of a value-based purchasing strategy under its multi-payer Patient Centered Medical Home (PCMH) program, which creates partnerships between CCTs and primary care practices. Maine expanded its existing PCMH efforts through the establishment of a health home practices (HHP) initiative for eligible Medicaid beneficiaries with chronic conditions. The CCTs provide wrap-around supports and services to help the HHPs manage care for the most complex, highest-need patients
  • Community Care of North Carolina (CCNC) is a public-private partnership between regional networks of physicians, nurses, pharmacists, hospitals, health departments, social service agencies, and community-based organizations. CCNC provides cooperative, coordinated care through the state’s Medical Home model, targeting the highest-risk patients and working to better manage their health and use of primary care services
  • The Vermont Chronic Care Initiative is a statewide program that provides intensive care coordination and case management services to Medicaid beneficiaries with one or more chronic conditions. The focus is on the top five percent utilizers of the healthcare system. The program’s health teams include: 1) A part-time medical director; 2) Registered nurses serving as care coordinators in provider practices and medical facilities; 3) Social workers; 4) Administrative staff; and 5) A pharmacist. Through the health teams, eligible individuals receive assistance with social service needs and medication management

Key takeaways/implications

  • States should consider purchasing strategies such as including CCT services as a requirement in provider delivery systems (e.g., accountable care organizations) and as a provision in managed care contracts
  • States may also look to Medicaid reimbursement for non-clinical preventive services that have been recommended by a licensed healthcare provider
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