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M INN E S OT A
A C CO UN T AB L E
H E A LT H
M O D E L
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S I M
M IN N ES O TA
SIM ACH Resources / Literature Review
Below is a summary of current literature and references on Community Care Team (CCT) and
Accountable Communities for Health (ACH) arrangements. Information was prepared by Atsushi
Sorita, Preventive Medicine Fellow at Mayo Clinic, one of three CCT pilots.
Contents
Minnesota Community Care Teams ........................................................................................................... 1
Community Care of North Carolina (CCNC) ................................................................................................ 2
Vermont Community Care Teams, Blueprint for Health ....................................................................... 3
Maryland................................................................................................................................................... 3
Agency for Healthcare Research and Quality (AHRQ) ........................................................................... 5
Centers for Medicare and Medicaid Services (CMS) ........................................................................ 7
Commonwealth Fund Resources ......................................................................................................... 9
Association of State and Territorial Health Officials (ASTHO) ............................................................ 10
US Preventive Services Task Force (USPSTF) ................................................................................. 12
Statewide Health Improvement Program/Community Transformation Grant (SHIP/CTG) 12
Theoretical framework for PC-PH collaboration ........................................................................... 12
Minnesota Community Care Teams
Since 2011, three Community Care Teams (Essentia Ely, Mayo Clinic Rochester, and HCMC Brooklyn Park)
along with Hennepin Health have been working on building successful models for integrated services
between health care, public health, behavioral health, social services, and other community partners.
The Community Care Teams (CCT) have developed new community partnerships that focus on prioritized
community health needs and service integration to address gaps in care through referral, transitions
management, and implementation of new practice guidelines. Lessons learned through the
development of and the on-going support of CCT was used as the basis for the development of
Accountable Communities of Health.
Vanderboom, C. E., Holland, D. E., Lohse, C. M., Targonski, P. V., & Madigan, E. A. (2013). Enhancing
Patient-Centered Care: Pilot Study Results of a Community Care Team Intervention. West J Nurs Res. doi:
10.1177/0193945913490841 Enhancing patient-centered care: pilot study... [West J Nurs Res. 2014] PubMed - NCBI
Information: www.mn.gov/sim
Contact: [email protected]
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Community Care of North Carolina (CCNC)
https://www.communitycarenc.org/
“Community Care of North Carolina: Improving Care Through Community Health Networks”,
Annals of Family Medicine, 2008
http://www.annfammed.org/content/6/4/361.long
- The program is an innovative effort organized and operated by practicing community
physicians
- CCNC was a grassroots response by practicing physicians, community health care leaders,
and state policy makers
- In partnership with hospitals, health departments, and departments of social services, these
community networks have improved quality and reduced cost over the past 25 years.
- The CCNC program has created community health networks organized and operated by
community physicians, hospitals, health departments, and departments of social services.
- Each network employs a full-time program director, a part-time medical director, and a team
of case managers
- Each network has a steering committee and medical management committee
- A statewide infrastructure, which helps to coordinate and support the 14 individual
networks provides direct financial assistance in proportion to the number of patients in the
network
- Key functions; Linking Patients to a Medical Home, Engaging Practices in Quality
Improvement Efforts, Case Managing High-Risk Patients, Planning Interventions and
Measuring Success, Providing Statewide Structure With Regional Control
o Each CCNC patient is linked to a medical home
o Community partners, such as local hospitals, health departments, and county health
departments and county departments of social services, are integral members of each
network, so that the CCNC medical practices are linked more strongly to the
community
o By joining a network, the practices gain access to a team of case managers who work
with all patients in a given network. A single practice may share a case manager with
several other small practices. The ratio of case managers to patients is generally high
(about 1:4,000). The group of patients in need of case management is identified
primarily through claims data
o Case management has been most successful when case managers and clinicians
regularly share treatment plans
- THE CREATION OF CCNC: KEY FACTORS
o Started Small
o Strong Physician Leadership From Outset
o Strong Office of Rural Health
o Best Practices From Pilot Programs
o Created During Crisis
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Vermont Community Care Teams, Blueprint for Health
http://hcr.vermont.gov/blueprint
http://www.commonwealthfund.org/Newsletters/States-in-Action/2009/July/June-July2009/Snapshots/Vermont-Community-Care-Teams-and-Health-IT.aspx
- 2013 Annual Report
http://hcr.vermont.gov/sites/hcr/files/Blueprint/Blueprint%20for%20Health%202012%2
0Annual%20Report%20%2002_14_13_FINAL.pdf
- “Vermont’s Blueprint For Medical Homes, Community Health Teams, And Better
Health At Lower Cost”, Health Affairs, 2011
http://content.healthaffairs.org/content/30/3/383.full
- Launched in 2003 and codified into law in 2006
- All citizens in the state will be able to participate
- Community health teams work with primary care providers to assess patients’ needs,
coordinate community-based support services, and provide multidisciplinary care for a
general population. A web-based central health registry will capture all patient data.
- Community health teams create a crucial link between primary care and community-based
prevention of chronic disease
- Each community health team is staffed by five fulltime-equivalent employees and serves a
population of approximately 20,000. The composition of any particular community health
team is determined locally, with input from area practices and hospitals, but teams typically
include nurse coordinators, behavioral health counselors, and social workers.
- They offer individual care coordination, health and wellness coaching, and behavioral health
counseling, and they connect patients to social and economic support services. In addition,
they perform community outreach to support public health initiatives.
- The behavioral health counselor also works in primary care practices. The fact that the
counselors work in a familiar setting lessens the reluctance some patients have to seek
mental health treatment.
- Primary care practices taking part in the pilots continue to receive fee-for-service payments
from insurers and Medicaid. In addition, they receive a per person per month payment based
on their National Committee for Quality Assurance score against patient-centered medical
home standards.
- The community health team’s cost is shared among Vermont’s three major commercial
insurers as well as Medicaid.
Maryland
- Community-Integrated Medical Home model
http://hsia.dhmh.maryland.gov/Documents/CIMH%20Project%20Narrative.pdf
http://hsia.dhmh.maryland.gov/SiteAssets/SitePages/payer-provider/SIM%205-913%20Slides.pdf
o The four pillars of this vision are (1) primary care, (2) community health, (3) strategic
use of data, and (4) workforce development
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Community Health Partnership in Baltimore
http://patientadherence.com/wp-content/uploads/2012/09/A-Qualitative-Evaluation-of-aCitywide-Community-Health-Partnership-Program.pdf
o The CHP utilizes a community health liaison (CHL) and a community health action
team (CHAT) consisting of community health leaders who are hands-on activists and
health care workers who coordinate activities and provide guidance for the CHP
Agency for Healthcare Research and Quality (AHRQ)
http://www.innovations.ahrq.gov/linkingClinicalPractices.aspx
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/
- At the 2010 Summit, stakeholders identified strategies to support local efforts to develop PCPH/community linkages for prevention, and recommended the development of metrics to
support related research
http://www.innovations.ahrq.gov/LinkagesReportTOC.aspx
o The linkages fell into several categories: (1) referral process, (2) provision of training
and resources to improve medical provider practices, (3) clinical partner referral to
health resources, (4) clinical partner volunteering at community programs, and (5)
other.
o Individual case analyses and cross-case analyses were conducted. Cross-case analyses
yielded further understanding of how linkages are developed and implemented and
how they contribute to delivery of clinical preventive services in the community. In
particular, the case studies revealed organizational, community, provider, and
intervention characteristics that serve as facilitators to the linkages.
o A wide variety of clinical and community partners can be engaged in these linkages;
key facilitators of developing linkages have to do with finding a compatible
organizational partner.
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The Clinical-Community Relationships Measures (CCRM) project, a collaborative effort to
explore how to define, measure, and evaluate programs that support the delivery of clinical
preventive services through clinical-community relationships.
-
CCRM Atlas
http://www.innovations.ahrq.gov/content.aspx?id=3879
http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinicalcommunity-relationships-measures-atlas/index.html
o The CCRM Atlas focuses on a subset of care coordination between clinics and
community-based resources that are not typically considered health care
organizations.
o Structure, Process, and Outcome domain categories
o Elements (clinic/clinician, patient, community resource) and Relationships
(between elements) measurement domains
o Based on socioecological model and expanded chronic care model
-
Clinical–Community Relationships Evaluation Roadmap
http://www.innovations.ahrq.gov/content.aspx?id=3973
http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinicalcommunity-relationships-eval-roadmap/index.html#
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Care Coordination Atlas
http://www.ahrq.gov/legacy/qual/careatlas/careatlas.pdf
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Centers for Medicare and Medicaid Services (CMS)
- Innovation Center
http://innovation.cms.gov/initiatives/index.html
-
Health Care Innovation Awards
o Funding up to $1 billion in awards to organizations that are implementing the most
compelling new ideas to deliver better health, improved care and lower costs to
people enrolled in Medicare, Medicaid and Children's Health Insurance Program
(CHIP)
o As of November 2013, grantees of the 2nd round are being selected
o Award project profiles
http://innovation.cms.gov/Files/x/HCIA-Project-Profiles.pdf
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Medicare Coordinated Care Demonstration (Ended in 2007)
http://innovation.cms.gov/initiatives/Medicare-Coordinated-Care/
o Evaluation summary
http://innovation.cms.gov/Files/x/Evaluation-of-Medicare-Coordinated-Care.pdf
o Tested whether care coordination programs can be applied in Medicare fee-forservice settings
o Few evidence that the demonstration resulted in improving patient outcomes
-
Community-based Care Transitions Program
http://innovation.cms.gov/initiatives/CCTP/
o Tests models for improving care transitions from the hospital to other settings and
reducing readmissions for high-risk Medicare beneficiaries
o Community-based organizations (CBOs) will use care transition services to effectively
manage Medicare patients' transitions
o The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of
care transition services provided at the patient level and of implementing systemic
changes at the hospital level
-
Multi-Payer Advanced Primary Care Practice Demonstration
http://innovation.cms.gov/initiatives/Multi-Payer-Advanced-Primary-Care-Practice/
o Participating States; Maine, Vermont, New York, Rhode Island, Pennsylvania, North
Carolina, Michigan, and Minnesota.
o The demonstration program will pay a monthly care management fee for beneficiaries
receiving primary care from advanced primary care (APC) practices.
o The care management fee is intended to cover care coordination, improved access,
patient education and other services to support chronically ill patients.
o Each participating State will have mechanisms to offer APC practices community
support and linkages to State health promotion and disease prevention initiatives.
-
Comprehensive Primary Care Initiative
http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/
o A multi-payer initiative fostering collaboration between public and private health care
payers to strengthen primary care
o Primary care practices that choose to participate in this initiative will be given
resources to better coordinate primary care for their Medicare patients
o Practices were selected based on their use of health IT, ability to demonstrate
recognition of advanced primary care delivery by accreditation bodies, service to
patients covered by participating payers, participation in practice transformation and
improvement activities, and diversity of geography, practice size and ownership
structure.
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FQHC Advanced Primary Care Practice Demonstration
http://innovation.cms.gov/initiatives/fqhcs/
o Show how the patient-centered medical home model can improve quality of care,
promote better health, and lower costs
-
Independence at Home Demonstration
http://innovation.cms.gov/initiatives/independence-at-home/
o Work with medical practices to test the effectiveness of delivering comprehensive
primary care services at home
o Selected primary care practices will provide home-based primary care to targeted
chronically ill beneficiaries for a three-year period
Commonwealth Fund Resources
-
Integration of Mental and Medical Health Care, Missouri
http://www.commonwealthfund.org/Innovations/State-Profiles/2011/Jan/Missouri.aspx
o Primary Care Nurse Liaisons and Community Mental Health Case Managers
o Building Bridges Between Medicaid and Mental Health Departments
-
Assessing and Addressing Legal Barriers to the Clinical Integration of Community Health
Centers and Other Community Providers
http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Jul/ClinicalIntegration.aspx
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Care Management for Medicaid Enrollees Through Community Health Teams
http://www.commonwealthfund.org/Publications/Fund-Reports/2013/May/CareManagement.aspx
o The report focuses on eight states—Alabama, Maine, Minnesota, Montana, New York,
North Carolina, Oklahoma, and Vermont—that provide funding in support of
multidisciplinary community health teams that are shared among multiple
practices.
o Core characteristics of the eight programs
 multidisciplinary care teams that coordinate services, promote self-management,
and help manage medications
 sustained, continuous relationships between patients and team staff that are
established and cultivated through regular face-to-face contact
 mechanisms to routinely send and receive information about patients between
practices and care teams
 whole-person care of patients identified as high-risk, high-need, or high-cost
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
a focus on transitions in care, especially between hospital and home team
members who routinely connect patients with relevant community-based
resources
 enhanced reimbursement for primary care practices that collaborate with teams
o A hallmark of the community health team is the early and ongoing engagement of primary
care providers throughout program development and implementation
o Expectations for community health teams
 team functions and composition; target population identification; patient care;
linkages with hospitals; electronic data tracking; practice education, including
helping primary care practices meet medical home standards and quality
improvement standards
o Data on the effectiveness of community health teams are very limited; with the exception
of Community Care of North Carolina. State programs have been in operation for less than
four years and generally are in the early stages of implementation
Association of State and Territorial Health Officials (ASTHO)
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Primary Care and Public Health Integration
http://www.astho.org/Programs/Access/Primary-Care-and-Public-Health-Integration/
http://www.astho.org/PCPHCollaborative/Strategic-Map-Info/
http://www.astho.org/pcph-strategic-map/identify-what-works/
http://www.astho.org/pcph-strategic-map/create-compelling-cases/
Provides comprehensive resource lists and success stories
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 National Governors Association
- Strategies for States to Encourage and Fund Community Care Teams
http://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/pagehealth-publications/col2-content/main-content-list/strategies-for-states-to-encoura.html
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Strategies that states can use to put such sustainable financing in place, either directly or
indirectly, include the following:
o Include the formation of community care teams in the specifications and funding of
medical or health homes to take advantage of the enhanced federal Medicaid financing of
health homes
o Adopt payment policies to reimburse for community care services, such as community
health workers, that offer incentives for the provision of such services under the states’
Medicaid and CHIP programs
o Include the provision of community care team services as a specification for directing
contracting arrangements with provider delivery systems, such as ACOs. Provide for
advanced payment to these systems to develop care teams
o Include the provision of community care team services in Managed Care Organization
(MCO) contract specifications for certain Medicaid populations
o Encourage the funding of community care team programs by private foundations,
charitable organizations and counties through grant making
US Preventive Services Task Force (USPSTF)
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Integrating Evidence-Based Clinical and Community Strategies to Improve Health
http://www.uspreventiveservicestaskforce.org/uspstf07/methods/tfmethods.htm
Statewide Health Improvement Program/Community Transformation Grant (SHIP/CTG)
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The Community Health Educator Referral Liaison Program, CDC
http://www.innovations.ahrq.gov/content.aspx?id=2244
SHIP Implementation Guides, Health Care (Clinical-Community Linkage) in the Strategy
Implementation Guide section
http://www.health.state.mn.us/healthreform/ship/Implementation.html
Healthy Northland (CTG Grantee), Clinical Care
http://www.healthynorthland.org/pages/default.aspx?id=130
Theoretical framework for PC-PH collaboration
1. Guide for medicine and public health collaboration
http://books.google.com/books/about/Pocket_guide_to_cases_of_Medicine_public.html?id=B
T9rAAAAMAAJ
Described six types of collaboration (Synergy I-VI)
2. The Community Oriented Primary Care (COPC) Model
 Community Health Worker Model and Family Health Strategy in Brazil
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681592/
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477957/#!po=34.6154
http://www.radcliffehealth.com/ljpc/article/integrating-primary-care-and-public-healthlearning-brazilian-way
Lay community health workers covering all households and communicate with primary care
providers and public health systems
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Community Care Network Demonstration Project
http://mcr.sagepub.com/content/60/4_suppl/5S.long
http://www.rwjf.org/reports/grr/029519.htm
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Community Oriented Primary Care
http://www.gru.edu/mcg/fmfacdev/fd_copc.php
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Safety Net Medical Home Initiative
http://www.safetynetmedicalhome.org/about-initiative
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Infrastructure for Maintaining Primary Care Transformation (IMPaCT)
http://www.ahrq.gov/research/findings/factsheets/primary/impactaw/index.html
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Primary and Behavioral Health Care Integration Program (PBHCI)
http://www.integration.samhsa.gov/about-us/pbhci
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Clinical-Community Linkages to Prevent Diabetes (CC-Link) study
http://www.ncbi.nlm.nih.gov/pubmed/20484325
Community-based partnership (full paper not accessible)
http://www.ncbi.nlm.nih.gov/pubmed/22608875
Cambridge Health Alliance
http://content.healthaffairs.org/content/30/3/435.full
- Home visits by a nurse for asthma children
- Funded by the Institute for Community Health http://icommunityhealth.org/
San Diego Prevention Research Center
http://www.ncbi.nlm.nih.gov/pubmed/23355255
Partnership with universities, FQHCs, and community advisory board
- Target Spanish population