Community Care Teams



Community Care Teams (CCTs) are community-based care coordination teams that have been implemented in multiple Medicaid programs. CCTs emphasize in-person contact with patients and integration of community resources and primary care services. The programs vary, but generally use methods including risk stratification, predictive analysis and utilization data to identify patients who would benefit from care coordination services. CCTs are typically paired with a patient-centered medical home model. The composition of each interdisciplinary care team varies from state to state and can include physicians, nurses, pharmacists, behavioral health professionals, social workers and non-clinical service providers. Versions of the CCT model have been implemented in over half a dozen states.

Partner Organizations

  • Community Care of North Carolina
  • Vermont's Chronic Care Initiative
  • Community Care of Central Colorado
  • Maine's Primary Care Medical Home Pilot
  • Montana's Health Improvement Program
  • Patient Care Networks of Alabama
  • Minnesota Community Care Teams
  • Adirondack Regional Medical Home Pilot
  • Oklahoma's Health Access Networks

Target Population

High-risk patients, predominately Medicaid enrollees

Care Team

Varies across states and populations served


2008 - present

Results/ Studies

Evaluation of Community Health Team model in Johnsbury, VT (2014)


Financing streams through Medicaid FFS and Managed Care Organizations (MCOs), Medicare and commercial payers


Center for Health Care Strategies description

Commonwealth Fund description

NORC overview of state approaches