What Is a Community Care Team?
A Community Care Team (CCT) is a group of multidisciplinary health care professionals who specialize in caring for people with multiple chronic diseases. The CCT helps patients better manage their diseases and links them with the resources and support they need. This keeps patients well and allows them to manage their diseases at home while preventing unnecessary hospital stays or ER visits.
At Lehigh Valley Health Network, we have several CCTs that support multiple primary care practices. If you receive care at a primary care practice supported by a CCT, your primary care doctor will determine if you can benefit from a CCT. If so, a team member may call you to get to know you better. Each team includes a:
- Registered nurse (RN) care manager who educates you about your diseases and treatments, reviews your hospital discharge instructions and medication list, ensures your doctor’s appointments are made and identifies other barriers interfering with your ability to stay well
- Pharmacist who identifies, resolves and prevents medication-related problems, educates you about why it’s important to take medication as directed, and identifies other medications that might be less expensive or work more effectively
- Behavioral health specialist who ensures your psychiatric well-being is addressed by providing brief therapeutic interventions and referring you to other behavioral health providers for ongoing treatment, if necessary
- Social services coordinator who completes a comprehensive assessment, helps solve problems that are preventing you from getting the care you need and provides support
A CCT is an extension of your primary care practice. Team members update your medical records and share information about you with your doctor in an effort to provide seamless coordination of your care. This allows your doctor to make decisions about your care based on the newest information.
CCTs also provide peace of mind. If your primary care physician recommends a CCT, you’ll receive a phone number you can call to talk directly to a member of your CCT when you have questions or concerns about your health.