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Community Care Team (CCT)

Community Care Team (CCT). Northwest Colorado. Mission Develop a regional network of care for Northwest Colorado to include oral health, behavioral health, health promotion, disease prevention, chronic disease management, and acute care for all age groups. Geographic Focus

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Community Care Team (CCT)

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  1. Community Care Team (CCT) Northwest Colorado

  2. Mission • Develop a regional network of care for Northwest Colorado to include oral health, behavioral health, health promotion, disease prevention, chronic disease management, and acute care for all age groups. • Geographic Focus • Moffat, Routt, Jackson, Grand, and Rio Blanco Counties • Partners include: • Mind Springs Health • Northwest Colorado Dental Coalition • Northwest Colorado Visiting Nurse Association • Routt County Dept. of Human Services • The Memorial Hospital • Yampa Valley Medical Center Community Care Team

  3. Community Care Team Care Coordinators: Valerie Koehn & Bret Sloan Team Lead & Integrated BH: Leah Hemeyer Project Coordination: Janie Dunckley ROUTT • Cindy – VNA/CHC Case Mgr. • Jenn – VNA/CHC Behavioral Health • YVMC Case Mgmt. • Frankie H. , PA – YVMA Care Coordinator for CPCI • Lindsay – Tobacco Cessation • Karla – Cardiovascular Outreach & prevention MOFFAT • Eveline – VNA/CHC Case Mgr. • Sandy – VNA/CHC Behavioral Health • Shantell– VNA/CHC Behavioral Health KEY Colors based on employer GREEN = Mind Springs Health GOLD = NWCOVNA BLUE = Primary Care/Hospital

  4. Patient & Family Centered Care Meet the patient where they are on the care continuum

  5. How we get clients? • RCCO Clients Using lists and tools from Medicaid & RMHP, our team targets high need (high ER use, readmits, etc.) clients. We outreach through “cold calls” and amazing PI work. • Hotspotting/Referrals Referrals from the hospital, PCMPs, human services, Horizons, home health, etc. for ANY high needs patient needing care coordination. Generally uninsured or underinsured.

  6. Community Care Team

  7. Community Care Team As our work expands in Moffat County, we are working on developing a stronger relationship with TMH. We currently do not have procedures in place to “hotspot” or be notified if our clients are in ER or admitted.

  8. Program Plan Metrics Local CCT Metrics RCCO Measurements Metrics are intended to measure the breadth and depth of our work. Initial Assessments Care Interventions/Care Plans Intense care coordination (3+ interventions within 30 days)

  9. Work at the Community Level • Outreach to all partners • Orienting everyone to our work, how we can help and how we can support you. • Understanding how everyone works together • Developing lines of communication that are useful for all in providing patient-centered care. • Working at the “macro” level to identify community needs and options to address (NCCHP level).

  10. Community Care Team Contact Integrated Care Coordinators Valerie Koehn - (970) 846-4788 Bret Sloan - (970) 812-7820 Team Lead & Integrated Behavioral Health Clinician Leah Hemeyer, LPC – (970) 846-4439 Project Coordination Janie Dunckley, MPP – (970) 217-9739

  11. Questions?

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