Community Health Teams

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Vision: Rhode Islanders with complex needs will have easy access to a system of care that addresses their physical, behavioral health, and social needs to improve their health, well-being, and patterns of utilization. Providers will know their patients and patients’ families and have access to readily available resources that address their individual needs.

Charge: To develop a statewide strategy for the development and spread, implementation, and evaluation of community health teams. Efforts of the Community Health Team Program Development Committee will be geared towards identifying a population that not only has high medical costs, but also has high-level of medical, behavioral and/or social needs, and can be impacted by engagement with a multi-disciplinary community health team.  The Committee will identify standardized processes, templates, and workflows for community health team interventions, identify gaps in resources and trainings, and improve coordination with primary care offices to address the social determinants of health and meet the full spectrum of physical, behavioral and social needs of Rhode Islanders. 

Resources
CHT Planning Charter
CHT Referral and Triage Tool
Researching Beyond Patient Centered Medical Home Walls
CHT Memorandum of Understanding (CHT/Practice)
CHT MOA with Health Plans, CHT  and Practices
Referral/Intake form
CTC-RI Community Health Team Pilot Program Final Evaluation Report, February 2016
CTC-RI Community Health Team Pilot Program Literature Review Part I: Community Health Teams and Complex Care Management for High-Risk Patients, 2016
CTC-RI Community Health Team Pilot Program Literature review Part II: Overview of Vermont’s Comprehensive Approach to Care Management and Improving Health Outcomes, 2016

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.