CCTs, also known as community health teams or care networks, are locally based care coordination teams. Their mission is to manage patients’ complex illnesses across providers, settings, and systems of care.
Unlike traditional disease management programs, which focus on specific chronic conditions, CCTs coordinate care between primary care providers and community resources, emphasizing in-person patient contact.
These teams are generally connected to patient-centered medical homes (PCMHs) and work collaboratively to assess patients’ needs, coordinate community-based support services, and provide multidisciplinary care1