|The CHANS Community Care Team (CCT) works as an extension of Patient Centered Medical Homes to identify people living with chronic diseases who need additional support in order to achieve their optimum health potential. The CCT works with physicians from Mid Coast Medical Groups in Bath, Brunswick, and Topsham, as well as Martin’s Point on Farley Road in Brunswick, and Wiscasset Family Medicine.
The CCT is comprised of a registered nurse, a clinical social worker, and an administrative assistant. The CCT helps patients identify barriers that may prevent them from staying healthy and then links them to supports and resources to help them remain on a healthy path. One of the primary goals of the CCT is to reduce patient visits to the emergency department and related hospital admissions.
Since becoming operational in January 2013, the CHANS CCT has received 109 referrals, has 52 active patients, and 19 people who have been discharged from services at the completion of their healthcare goals. The work of the CCT has improved the overall quality of life for each of the patients they serve.