Appendix 2

A Community Health Team (CHT) is a team of allied health professionals, including behavioral/mental health specialists, community outreach/prevention specialists (responsible for linking the patientcentered medical home or primary care practice with community-based prevention resources), nurse care coordinators (such as nurse practitioners) that provide multidisciplinary care support to primary care practices across a community. Their goal is to provide expertise designed to prevent disease and provide higher quality lower cost health care particularly targeting chronically ill patients.

CHTs work with small primary care practices that do not otherwise have the resources to serve as a medical home or offer comprehensive disease management programs to implement care plans for chronically ill patients. Appropriately implementing a chronic care plan requires coordinated health care interventions and communications, including significant patient self-care efforts, systemic supports for the physician-patient relationship, a plan of care emphasizing prevention of complications, patient empowerment strategies, and the evaluation of clinical and economic outcomes on an ongoing basis.

Working closely with the primary care practice, the CHTs would coordinate individual patient care support, population management and plan ongoing quality improvement. In addition to care management, their functions include coaching, patient/family contact, assessment, transitional care management (from hospitals, nursing homes, home health agencies), reinforce the treatment plan, patient education, reminders and self-management.

One of their most important functions is the responsibility for providing both 24/7 on-going care management and transitional care. Medical homes and CHTs would work with physicians at discharge from the hospital to reconcile medications and create postdischarge care plans, provide 24-hour post-discharge care and serve as liaisons to community based prevention and treatment programs.

In order for CHTs to have maximum flexibility to work with patients “holistically,” they should not be subject to the constraints or incentives of fee-for-service billing arrangements. For example, North Carolina, Vermont and West Virginia approach funding through a combination of federal and states grants, and contracts with primary care practices.

A Community Health Team (CHT) is a team of allied health professionals, including behavioral/mental health specialists, community outreach/prevention specialists (responsible for linking the patientcentered medical home or primary care practice with community-based prevention resources), nurse care coordinators (such as nurse practitioners) that provide multidisciplinary care support to primary care practices across a community. Their goal is to provide expertise designed to prevent disease and provide higher quality lower cost health care particularly targeting chronically ill patients.

CHTs work with small primary care practices that do not otherwise have the resources to serve as a medical home or offer comprehensive disease management programs to implement care plans for chronically ill patients. Appropriately implementing a chronic care plan requires coordinated health care interventions and communications, including significant patient self-care efforts, systemic supports for the physician-patient relationship, a plan of care emphasizing prevention of complications, patient empowerment strategies, and the evaluation of clinical and economic outcomes on an ongoing basis.

Working closely with the primary care practice, the CHTs would coordinate individual patient care support, population management and plan ongoing quality improvement. In addition to care management, their functions include coaching, patient/family contact, assessment, transitional care management (from hospitals, nursing homes, home health agencies), reinforce the treatment plan, patient education, reminders and self-management.

One of their most important functions is the responsibility for providing both 24/7 on-going care management and transitional care. Medical homes and CHTs would work with physicians at discharge from the hospital to reconcile medications and create postdischarge care plans, provide 24-hour post-discharge care and serve as liaisons to community based prevention and treatment programs.

In order for CHTs to have maximum flexibility to work with patients “holistically,” they should not be subject to the constraints or incentives of fee-for-service billing arrangements. For example, North Carolina, Vermont and West Virginia approach funding through a combination of federal and states grants, and contracts with primary care practices.

Contents

Follow Us On:

 

Follow Us On: