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CTC CHT Services and Resources

 

Community Health Team Newsletters: 

March 2020 Newsletter 

December 2019 Newsletter 

 

Resources: 

Community Health Team Video 

Community Health Team Map

 

Family Care Liaison:

As care coordinators, you may need help to identify resources to address child and family needs. The Family Care Liaison is a new resource for care coordinators and nurse care managers at PCMH-Kids practices.

What can the Family Care Liaison do?

The Family Care Liaison will assess the needs and eligibility of the child or children and identify and coordinate with appropriate programs to meet their needs

  • Enhanced care coordination through RIPIN’s Cedar Family Center
  • School supports from RIPIN’s special education experts
  • Family support from RIPIN Peer Professionals
  • Other relevant programs, both inside and outside RIPIN

RIPIN's new Family Care Liaison can help any family with a child

  • In need of in-home services
  • Whose family is at risk for food or housing insecurity
  • Whose parent presents as overwhelmed with their child's needs
  • Whose family is affected by Substance Use Disorder (SUD) or at risk for Opiate Use Disorder (OUD)

 

RIPIN- Family Care Liaison

 

Multidisciplinary Family Care Team:

The goal of this collaboration is to pilot a cross-agency, cross-discipline, intentionally-designed team approach to serve families (children and adults) with complex medical, behavioral and social needs. The intention is for this pilot to specifically serve families affected by Substance Use Disorder (SUD) or at risk for Opiate Use Disorder (OUD). The Family Care Team brings together people from the different agencies and programs families are working with in order to facilitate information sharing and provide more streamlined support.  This includes representatives from the client’s Family Home Visiting team and Community Health Team (CHT).

Family Care Team meetings happen weekly.  During these meetings, information is shared about the family needs, referrals made, and progress made towards achieving goals. Gaps are identified and action steps are outlined.  Having representatives from the key agencies involved in providing family support is essential to the success of this pilot.  Families are invited to participate in these meetings.

 Patient Benefits
  • Improved overall patient and family care
  • Decreased gaps in care
  • Improved service coordination
  • Expedited referral process
  • Improved care planning
Staff Benefits
  • Streamlined treatment pathways and reduction in duplication of services
  • Improved collaboration and communication between providers
  • Increased educational opportunities
  • Ability to share and learn about valuable community resources
  • Decreased staff burnout through collegiate support

 

MDT Pilot One Pager

 

Our Mission

The mission of the Care Transformation Collaborative 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.