LVHN’s community care teams connect you to the resources and support that can help you better manage ongoing health concerns. 

CCTs support primary care practices. If your provider believes you would benefit from a CCT, you will be connected with one and be able to contact them whenever you have questions or concerns about your health.

How does a community care team help manage my health?

The CCT is an extension of your primary care provider. Members of your CCT update your medical records and share your health information with your primary care provider so they can seamlessly coordinate your care. With these up-to-date details in your chart, you and your provider can make better health care decisions for you.

In addition to keeping your records current, CCTs help you:

  • Effectively manage your health
  • Prevent unnecessary hospital stays
  • Avoid trips to the emergency room (ER)
  • Identify helpful community resources
  • Assist with some of the social barriers to health care, such as transportation or the cost of prescriptions

Which types of providers are part of the CCT and what patient care services do they provide?

Registered nurse (RN) care manager 

A nurse liaison is the primary team member and you will interface with this person most. She or he will:

  • Educate you about your conditions and treatments
  • Review your hospital discharge instructions and medication list
  • Ensure you make your doctor’s appointments
  • Identify other barriers interfering with your ability to stay well


Pharmacists play an essential role for patients with chronic illnesses who are on multiple medications to manage their disease. CCT pharmacists:

  • Identify, resolve and prevent medication-related issues
  • Educate you about why it’s important to take medication as directed
  • Identify other medicines that might be less expensive or work more effectively 

Behavioral health specialist 

Patients dealing with more than one chronic illness may need behavioral or mental health support. This team member:

  • Addresses your psychiatric well-being by providing therapeutic interventions
  • Refers you to other behavioral health providers for ongoing treatment, if necessary

Social services coordinator 

To aid you in effectively navigating everyday life despite your disease, our social services coordinator:

  • Completes a comprehensive assessment to identify concerns
  • Helps solve problems that are preventing you from getting the care you need

Provides other ongoing support and assistance, such as transportation or help with insurance matters