Abstract
Purpose/Objectives: The purpose of this study was to describe lessons learned during the development and implementation of a community care team (CCT) and the applicability of this model in movement toward cross-sector team-based care coordination.
Primary Practice Setting: Primary care.
Findings/Conclusions: Cross-sector CCTs composed of primary care and community service providers are a care coordination approach that attends to the individual's social determinants of health, enhances the individual's capacity to manage treatment and self-care demands of multiple chronic health conditions, improves the care experience, and impacts well-being. A collaborative CCT decreased the use of acute care services and the costs of care.
Implications for Case Management Practice: As reported in this study, use of interprofessional collaborative health care teams in planning care and services for individuals is a standard of practice for case management. Cross-sector partnerships provide the opportunity to maximize the contributions of health care and community service providers that address both chronic health conditions and social determinants of health, minimize fragmentation and costs of care, and promote collaborative care coordination. Community care teams offer sophisticated care coordination not otherwise available to medically complex high-need individuals who require assistance in navigating the medical and financial systems that exist in health care today.