The effective management of patients' complex illnesses across providers, settings, and systems places extraordinary demands on primary care providers, especially those that work in resource-limited small or rural practices. Medicaid programs in some states have adopted strategies to build practice capacity to care for high-need Medicaid beneficiaries through the development of local community health teams, with members in fields such as nursing, behavioral health, pharmacy, and social work. Using data from a 2011--2012 review of state Medicaid medical home programs, we identified community health team programs in eight states that provide an array of targeted services, from care coordination to self-management coaching. The programs feature frequent in-person contact with patients and integration with primary care providers and community resources. Early data suggests this model may reduce costs and improve quality while enabling many resource-strained practices to offer a full array of medical home services.
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