The Community Health Team model works as an extension of primary care to support patients by facilitating access to community-based services to address complex social, environmental, medical, and behavioral health needs. CHTs work with primary care providers to:
Community Health Teams serve culturally-, linguistically-, and economically-diverse patients who meet the high risk criteria identified, including experiencing significant medical needs, behavioral health needs and social needs.
Individuals are being screened at intake. Results show:
Our CHTs are also serving individuals with complex social issues and are able to develop care plans to address these social needs.
“CHTs have improved the integration of medical, behavioral, social and substance-related healthcare in the state of RI, showing substantial improvements in health risk, social determinants of health, behavioral health and wellbeing for these high risks, high need patients.” *
* Redding C.A. (2019, August) SIM Community Health Team Final Evaluation Report. Prepared by University of Rhode Island State Evaluation Team. Rhode Island State Innovation Model Grant #1G1CMS331405. Retrieved from Rhode Island State Innovation Model
A Brown University study examined the South County Community Health Team (CHT) using the All-Payer Claims Database information (2014-2018) against a matched comparison group using a difference in differences analysis to compare the CHT cohort and a control cohort. Looking at 12 months before and up to 12 months after the start of the intervention, the study found a difference of $1563 in total cost of care for each quarter after CHT enrollment. The CHT average length of enrollment was 9.1 months and there was an average annual cost per client of $1625. Using the cost savings produced in the evaluation, there is an annual return on investment of $2.85 for every $1 spent.
Findings from a recent evaluation completed by the University of Rhode Island* confirm that the program is serving the intended patient population and supports the effectiveness of the CHT model. Over the course of the study, several statistically significant and clinically meaningful changes were demonstrated:
Clinically & Statistically Significant Client Changes after 4.7 months of CHT Care
Evidence suggests that embedding SBIRT within CHTs significantly reduces patients’ substance use behaviors. People who received brief substance use interventions reduced their past 30-day substance use by 30-40% at 6-month follow up.
Data from one large partner site demonstrated that in spite of high levels of health and social needs, clients who participated in CHT care met or exceeded most UDS targets for quality medical care.
To fully build out and sustain the CHT integrated team model, CTC-RI has convened a Board-level public/private Oversight Committee to lead a robust effort to:
The mission of the Care Transformation Collaborative of Rhode Island is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations we serve.