Community Team

Page heading background of people in crop field

Organization Information

Project Summary

The Community Team utilizes an integrated care model with a whole person approach designed to improve the care of a targeted group of members with complex needs and high costs of care, including individuals with both physical and behavioral health conditions. The team-based approach draws on the unique skills of nurses, social workers, certified peer specialists/ community health workers/health coaches, as well as pharmacist and medical director support to assist members with complex needs and high utilization of inpatient care. Contact is established face to face in the hospital followed by ongoing visits and support in the members' homes to create therapeutic bonds, help build members' knowledge and self-management skills, improve care coordination among their providers, and identify and help overcome medical and psychosocial barriers to care. The Community Team health coaches meet and engage members in the community, establishing rapport, assisting with transportation needs and often accompanying members to physician visits. They help to improve members' understanding of their current health conditions, conduct psychosocial assessments and use motivational interviewing to identify members' goals and pinpoint their readiness to change. By meeting with members on their terms in their homes and communities, the health coaches are better able to understand the factors that affect their motivation and leverage those factors to promote personal responsibility in members' everyday choices for positive health outcomes.

Project Goal

The key goal of the program is to reduce unplanned care including preventable readmissions and ED visits. This is accomplished using a comprehensive approach to improve members' knowledge, self-management abilities, understanding of their medications and importance of compliance, and addressing any social determinants of care that may contribute to readmissions.

Promotional Methods

UPMC for You members with 2 or more inpatient admissions, physical and/or serious behavioral health disorders, and a high care need index (greater than 3 out of 5), are identified while in the hospital for outreach from the Community Care Team.

Project Challenges

A key challenge in assembling the Community teams was finding and hiring Certified Community health Workers (peer specialists). Although this was accomplished over time, it delayed full deployment of the teams. Establishing contacts with and/or developing community health worker training programs is vital in maintaining a coummunity health-based work force.

Project Results

From July, 1 2015 through January 31, 2016, members participating in Community Team increased from 197 to 642. The 30 Day All-Cause Readmission Rate decreased from 16.9% to 8.3% (-50.9%) during this time period. From September 1, 2015 through March 31, 2016, The inpatient admission rate/1000 for Community Team Members decreased from 1,030 to 812/1000 (-21.2%) and the ED rate/1000 decreased form 4275 to 2751/1000 (-35.6%).

Organization Type


Types of Practices

  • Community

Target Age Ranges

  • Adults
  • Families


  • All


  • All

Project Service Type

  • Community Outreach / Community Engagement
  • Disease Management (long-term)
  • Disease Treatment / Risk Treatment
  • Other
  • Prevention

Project Content Area

  • Behavioral Health
  • Cardiovascular Disease (general)
  • Chronic Disease (general)
  • Health (general)
  • Health Equity
  • Mental Health
  • Nutrition
  • Physical Activity
  • Tobacco Cessation
  • Violence / Injury Prevention (general)

Project/Program Care Team Target Population

Counties Served

Uploaded Documents/Images