South County Community Health Team Essay

2136 Words9 Pages
South County Community health team is an agency under South County Hospital that works with Primary Care Physicians to assess and assist at risk patients. The funding for the six employees comes from a grant through the Care Transformation Collaborative. A department of office of the health insurance commissioner and the executive the 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, p. 2) .The community health team is compiled of six women ranging from 22-60 years old. All of which are Caucasian except myself of Native American and African American decent much like the Washington county of population that is served. The team consists of one IT programmer, a LICSW, a Behavioral Health Care Manager (BHCM), a team lead and two Community Health Workers (CHW). My role on the community health team is a visiting Community health worker 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 Community Health team 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
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