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.
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.
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.
Diane E. Holland, PhD, RN, is a nurse scientist, Department of Nursing, and associate professor, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN. She is a fellow, Gerontological Society of America and American Academy of Nursing. Her research interests include transitioning adults from the hospital to primary care in the community.
Catherine E. Vanderboom, PhD, RN, is a nurse scientist, Department of Nursing, and assistant professor, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN. Her research interests include community-based interventions, especially care coordination, for older adults with multiple chronic health conditions.
Tanya M. Harder, MSN, PHN, RN, CCM, is a public health nurse manager, Olmsted County Public Health, Rochester, MN. Her interests include case management of low-income seniors in a community-based setting and interprofessional collaboration to ensure safe and effective transitions across care settings.
Address correspondence to Diane E. Holland, PhD, RN, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (firstname.lastname@example.org).
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