title: Developing a community care team: lessons learned from the community connections program, a health care home-community care team partnership.
abstract: This article describes the development of the Community Connections Program (CCP), a community care team, within a health care home (HCH), as a short-term, intensive, team-based service planning and coordination program for older adults with multiple chronic health conditions. Three proven approaches were combined to support patient's self-management, nurse care coordination, the Wraparound process, and use of community services. Particzpants'responses to the CCP demonstrated the success of the community care team in connecting patients and nurse care coordinators (NCCs) with community service providers, thus supplying primary care providers with important information regarding the development of a community care team to support patient-centered care within a HCH.
authors.affiliation: Department of Nursing at Mayo Clinic in Rochester, MN, USA. vanderboom.catherine@mayo.edu
authors.forename: Catherine E
authors.initials: CE
authors.lastname: Vanderboom
authors.forename: Diane E
authors.initials: DE
authors.lastname: Holland
authors.forename: Paul V
authors.initials: PV
authors.lastname: Targonski
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Madigan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease / Q000451:nursing*; D003695:Delivery of Health Care / Q000458:organization & administration*; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008875:Middle Aged; D009740:Nursing Staff / Q000458:organization & administration*; D010348:Patient Care Team / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development / Q000379:methods; D012648:Self Care / Q000379:methods*; D014481:United States