The alignment of multiple dynamic, highly diverse health and social service delivery systems is an ever-evolving endeavor.  In this session, we review the Community Care Team (CCT) model that has been developed in the Region Six Integrated Delivery Network (IDN).  The CCT is a working group comprised of decision-making representatives from over 50 clinical and non-clinical agencies and organizations that serve the most vulnerable members of our communities.   The CCT is a functional exposition of “the network” in which service and support systems operate, and that creates a space in which those systems can be concurrently observed, understood, and aligned in real time.   After describing the structure and functions of the CCT, we review cases that demonstrate its value for enhancing the accessibility to, and integration of behavioral, medical and social service assets to improve the health and wellbeing of the people we serve.   Likewise, we describe CCT value to service providers in cultivating shared awareness and enhancing coordination through reducing systems gaps, redundancies, and incongruities, while building network awareness, resilience, and capacity to meet the ever-changing priorities and needs of consumers.  At the end of this session, participants will be able to: provide a basic description of the CCT Model; describe the key tasks required to start and develop a CCT; describe the basic operations and tools used in a CCT; describe the value of a CCT for coordinated and integrated care models across a network of clinical/non-clinical entities; describe the value of the CCT for network development and systems alignment. This presentation may include breakouts where small groups engage with real CCT cases as a way to demonstrate the different types of value of the CCT.

Presented by Sandra Denoncour, BA, ASN, RN & Tory Jennison, PhD., RN

Sandra Denoncour, BA, ASN, RN Sandra recently moved from Lamprey Health Care to become Director of Care Coordination at the Region 6 IDN. While at Lamprey Health Care she was a Practice Manager in an integrated primary care behavioral health and OB/GYN services practice. Sandi has a Bachelor of Arts Degree from UNH and an Associate Degree in Nursing from Great Bay Community College.

Tory Jennison, PhD., RN Tory is the Director of Population Health/ Region 6 (Seacoast/Strafford) Integrated Delivery Network. She has 21 years of experience working in, designing, leading, and evaluating clinical and administrative coordination of multi and interdisciplinary teams across acute, primary, and home-based health care including integration of social non-clinical supports. Additionally, she has many years’ experience building resilient community-based systems of care across diverse populations. Ms. Jennison holds a PhD in Public Affairs from the University of Central Florida and a MS in Nursing Administration from UNH.