Community Care Teams were created across Maine in response to incentives and program opportunities within the National Committee for Quality Assurance's (NCQA) Patient-Centered Medical Home pilot. In a very short time, they've grown to be important members of the care teams allowing providers to get a 360 view of their patients.

  

 "We are proud of what our program can do for these patients," shares Ralph McPherson, LCSW, Beacon Health team lead in Aroostook County. This didn't happen overnight, when the CCTs were formed practices weren't really sure what they were and how to best use the program. "Now practices seek us out to support specific patients so we can surround them with services so they cannot only meet their healthcare needs, but their basic needs. The practices seem to truly value what the CCT has to offer their patients."

  

Ralph is especially proud of the Hospital to Home program, which provides follow-up visits to recently discharged patients. "We help arrange post-discharge care and assist with medication questions." These added measures have helped many patients avoid medication complications, gaps in care, or even hospital readmission.

  

An obvious comparable service might be home health services, but according to Ralph, "the only way we are the same is that we go through the client's front door." CCTs are not restricted by the many regulations enforced on home health agencies, including a prescribed list of services that can be rendered (and reimbursed) or the requirement that a client be home-bound. Also, because they are integrated with the primary care practices, CCT can often begin services very quickly, with less authorization and referral paperwork.

  

However, community care teams do not take the place of home health services. Often times, once CCTs make a connection with patients and find out what their specific needs and requirements are, they facilitate referrals to home health agencies to help bridge gaps in care.

  

In many ways, CCT is an extension of the primary care practice. They help patients follow through with their provider's recommendations, assist in setting up appointments, spend the time with clients to process and understand the last visit or test results, offer support to help avoid emergency department visits or readmissions, and sort through the often confusing array of medications that a client may have collected from multiple care sources. All this at no extra cost to patients!

  

  This level of care is an investment in time, some visits last up to 90 minutes, but the relationships that are made are essential to supporting patients living their fullest life. "The most important aspect of our jobs is to be sure that we identify any urgent concerns and any barriers to care, including self-care," shares Alison Ashley, LCSW, Beacon Health CCT central region.

  

Community care teams are a good combination of medical and mental health approaches. "The program allows staff to address the psycho-social needs of the client, which can be especially important for clients with anxiety or other disorders that prevent them from getting out of their homes and seeking appropriate care," explains Ralph.

  

Beacon Health CCT program manager Jaime Rogers says, "We have an uncanny ability to do wild and crazy things to address a client's need." She shared a recent success where a team member found a spanish-speaking pharmacist near a Latino client's home who cleared up the client's confusion about his diabetes medications and instantly improved the client's blood sugar levels, and therefore his ability to function during his day.  

  

"We are really offering a wonderful service," smiles Jaime, who feels that the program should be available to all of a practice's patients, not just those on the list from the health plan (or their occasional "exception"). "Practices and PCPs shouldn't have to make these distinctions about who can receive the help they need to get and stay healthy!"