Community Care Teams: An Overview of State Approaches

Publication Year: 2016
Patient Need Addressed: Care Coordination/Management
Population Focus: Medicaid beneficiaries
Intervention Type: Staff design and care management
Type of Literature: Grey

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.

Insights Results

Overview of article

  • This white paper provides information about Community Care Teams (CCTs) and includes an overview of core program features, governance structures, financing, and health informatics. The paper includes several state examples, but draws heavily on CCT models in North Carolina and Vermont
  • CCTs, also called community health teams (CHTs) or care networks, are locally-based care coordination teams employed to manage patients’ complex illnesses across providers, settings, and systems of care. The goal of the CCT is to support primary care providers in delivering quality-driven, cost-effective, and culturally appropriate patient-centered care. Unlike traditional disease management programs, which focus on specific chronic diseases, CCTs coordinate care between primary care providers and community resources, and emphasize in-person contact with patients. CCTs are generally connected to patient-centered medical homes (PCMH), and work with PCMH practices to assess patients’ needs, coordinate community-based support services, and provide multidisciplinary care


  • States have taken several approaches in developing authority for CCTs, such as regulatory policies, or using action through executive or legislative authority. For example, Vermont passed legislation in 2009 that requires state-regulated health insurers’ participation in the state’s patient-centered medical home effort, Blueprint for Health, including established reimbursement rates for community health teams
  • States and communities have created operational approaches that support the oversight of care teams. For example, in North Carolina, Community Care of North Carolina (CCNC) has an established partnership between Medicaid, primary care physicians, and other local healthcare providers to achieve quality, utilization, and cost objectives in the management of care for Medicaid recipients
  • The engagement of multiple sectors is critical for building effective CCTs. Collaboration among many stakeholders such as healthcare providers, patients/patient advocates, and community organizations ensures that the diverse range of patients and needs are represented. For example, the Vermont Blueprint for Health includes a robust stakeholder strategy. The design of the patient-centered medical home approach and community health teams involves primary care practices, hospitals, health centers, provider networks, insurers, elected officials, as well as consumers
  • As states implement a variety of care team models, they often develop pilot programs as incubators to inform the future development of statewide models. It can often take several years to realize, test, and evaluate models in order to develop the necessary infrastructure to support the model and demonstrate return on investment (ROI). Key factors cited for enabling the scaling and replication of care teams include: an assessment of the health status and needs of the population in the specific geographic area, an inventory of the existing infrastructure of community supports and services, assessment of provider capacity, and committed leadership to champion efforts
  • In addition, many states are looking at community health workers (CHWs) to play an integral role on community health teams. CHWs can serve as the link, or intermediary, between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery

Key takeaways/implications

  • Overall, CCTs can be an important piece of a broader healthcare transformation approach. CCTs complement a PCMH by increasing a practice’s capacity, and help to address the behavioral health, chronic conditions and social needs of high-risk patients—including Medicaid beneficiaries. The multidisciplinary nature of CCTs are well-suited to ensure that the full range of patients’ health and social needs are addressed, potentially reducing disparities in care and improving health outcomes