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South County Community Health Team Essay

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South County Community health team (CHT) is small agency housed in the larger South County Hospital that works with Primary Care Physicians to assess and assist at risk patients. Care Transformation Collaborative funds six employee positions on the CHT through the department of health insurance commission and the executive office of health and human services to “promote integrated, patient and family centered care data driven quality improvement, and prepare practices to perform successfully under Alternative payment models” (CTC, 2014, p. 2) .The CHT is compiled of six women ranging from 22-60 years of age. All of which are White except myself of Native American and African American decent which mirrors the demographic in Washington county that is served. The team consists of one Data Analysis, a LICSW, a Behavioral Health Care Manager (BHCM), a team lead and two Community Health Workers (CHW). My role on the CHT is a part time visiting CHW with an active caseload of 25 clients. I work closely with clients to provide resources to help them manage their care and wellbeing. Patients get referred from their Primary Care Physician that have high risk factors reported by the patient’s insurance company. The CHT works alongside Nurse Care Managers in Primary Care provider offices to assist clients that have complex medical conditions, behavioral health issues, substance abuse complications, social disorders. The goal of the South County Community health team is to improve

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