Rhode Island Community Health Teams: Coordinating with Primary Care to Address Social and Behavioral Health Needs

Kelsey Brykman, Center for Health Care Strategies

Primary care plays a central role in providing and coordinating care for individuals with complex health and social needs. At the same time, primary care practices often lack the necessary staff and resources to coordinate care across the health system or comprehensively address patient behavioral health and social needs, which are important drivers of poor health outcomes. One model to address this challenge is implementation of community-based care teams that can coordinate with and supplement the work of primary care providers to improve patient access to medical care and social supports.


Program Snapshot

Program: Rhode Island Community Health Teams

Population: Adults with complex medical, behavioral health and/or social needs

Goal: Provide community-based services to support primary care practices in coordinating care and addressing behavioral health and social needs.

Key Features: Multiple provider organizations across the state of Rhode Island operate multidisciplinary teams, including community health workers and behavioral health clinicians, that collaborate with primary care practices to provide whole-person care. Program evaluations have found positive impacts, including lowering health care costs and improving health outcomes.

The Rhode Island Community Health Team model (CHT) is implemented by multiple provider organizations across the state and was historically supported by the Care Transformation Collaborative of Rhode Island (CTC-RI). Convened by Rhode Island government agencies, CTC-RI is a non-profit organization that leads a variety of primary care-focused initiatives. First implemented in 2014, the CHT model evolved out of the recognition by Rhode Island stakeholders that additional services outside the walls of primary care clinics were needed to improve health outcomes for patients with complex needs. Behavioral health and social needs were often drivers of poor health outcomes, and many practices lacked capabilities to address these issues. Drawing on lessons from both Rhode Island primary care transformation efforts and community-based models in other states, CTC-RI and provider organizations collaborated to design and pilot the CHT model. As of 2022, four of the pilot provider organizations continue to implement CHT models and many additional organizations have started up similar models of care.


CHTs consist of multidisciplinary care teams that coordinate with and function as an extension of primary care practices to address patient physical health, behavioral health, and social needs. Teams include at least one behavioral health clinician and two community health workers and frequently include additional staff such as practice-based nurse care managers, peer recovery specialists, and administrative staff. High-risk patients, such as those with high health care utilization, multiple chronic conditions and/or unmet social needs, are typically identified and referred to CHTs through primary care. CHT services are generally payer agnostic, serving Medicaid, Medicare, and commercial and uninsured patients.

CHTs conduct health risk assessments, behavioral health and social needs screenings, and work with patients to address identified needs through care coordination, outpatient behavioral health services, and addressing social barriers. Length of time patients are engaged in the program depends on need and can vary from a few months to multiple years. The relationship and model for coordinating between primary care practices and CHTs varies by site, with some more practice-based and others more geography-based (e.g., serving many practices within an area). CHTs coordinate with primary care teams via various mechanisms, including regular telephonic case reviews, ad-hoc telephonic consultations, and, when applicable, shared electronic health records.

Over time, aspects of the CHT model such as staffing, patient identification and eligibility, service offerings, and number of sites served have evolved based on available funding, identified gaps in services, and implementation lessons. As described below, the financing of Rhode Island CHTs changed in March 2022 which may have an impact on how the model is carried out in the future.

Community Health Worker Role

The community health workers (CHWs) on CHTs help fill existing gaps in the health system by working outside the walls of primary care practice. Because CHWs are able to meet patients in the community and even in patients’ homes, they are often better positioned than clinic-based staff to holistically understand patient needs, particularly unmet social needs, and collaborate with patients to develop care plans. CHWs have the flexibility to help address patient needs in a variety of ways including through helping patients navigate the health system, securing benefits (e.g., insurance, financial assistance, housing support, etc.), offering health education, and providing emergency assistance (e.g., food or medicine drop-offs).

By working within communities, CHWs can help patients access care. For example, at Thundermist, CHWs frequently assist patients with securing transportation to appointments through a medical Uber service. Additionally, CHWs frequently accompany patients to medical appointments, allowing CHWs to understand barriers encountered, provide in-the-moment coaching, and debrief after appointments. CHWs also serve as patient advocates, helping patients understand their rights when issues arise such as a lack of needed interpreter services. CHWs can also help with securing medications and other appointment follow-ups.

Including CHWs on CHTs also helps enhance health system and community connections to address patient needs more comprehensively. For example, over the past couple years, South County CHWs have been trained on how to conduct structured coaching to help patients managed specific disease conditions. The health coaching has aligned well with another project in which South County CHT staff worked with a food pantry to run cooking classes. CHWs have been able to refer patients to these cooking classes to learn how to make healthy, medically appropriate meals.

Financing and Sustainability

The funding source and structure for RI CHT’s has varied both over time and by implementing provider organization. Between 2014 and early 2022, CTC-RI played a key role in securing grant and health plan funding to support provider organizations for CHT implementation. Initially, CTC-RI leveraged funding from public and private payers in the state to support CHT pilots at two sites. Following positive experiences with implementation, the health plans continued to support through grant funding and the state allocated federal grant money, including from State Innovation Model and Substance Abuse and Mental Health Services Administration awards, to CTC-RI to support expansion of the model to additional sites. CHTs were also supported through the Rhode Island Health System Transformation Program, a Medicaid delivery system transformation initiative funded through enhanced federal Medicaid dollars. Funding through CTC-RI was provided through a cost-based reimbursement methodology and covered CHT staff, including individuals in care delivery and program administration roles — some provider organizations supplemented this funding with other sources.

Currently, the program has transitioned away from the more centralized funding provided through CTC-RI. Provider organizations implementing CHTs have developed individualized sustainability plans. For example, some services delivered by behavioral health clinicians are billable under current Medicaid, Medicare, and Commercial plan polices. Some provider organizations are self-funding non-billable aspects and are exploring or have secured other grant funding.

Going forward, another key component of sustaining CHT activities is a new Medicaid CHW benefit. Rhode Island’s Executive Office of Health and Human Services recently submitted and received federal approval for a State Plan Amendment allowing Medicaid coverage of CHW services related to “health promotion and coaching; health education and training; health system navigation and resource coordination services; and care planning.” The benefit allows providers to be reimbursed for CHW services on a fee-for-service basis, based on 15-minute increments. While this will not fund the full breadth of CHT or CHW services, the benefit is one important means of supporting CHW access for Medicaid beneficiaries. Because the benefit was approved in spring 2022, provider organizations are still in the process of working to implement billing. One sustainability barrier is lack of multi-payer (e.g., commercial, Medicare) payment for CHW services.


Multiple evaluations have found positive impacts from the CHT program, including in terms of lowering health care costs and improving health outcomes:

  • A study conducted by Brown University, evaluating South County data for individuals covered by Medicare and/or Medicaid, found statistically significant reductions in emergency department (ED) costs and total costs. Individuals being served by CHTs had $1,564 lower total costs and $108 lower ED costs per quarter compared to the matched comparison group. Statistically significant changes in cost were not found in other cost categories, though inpatient costs were lower for CHT participants at a non-statistically significant level. Using that information, CTC-RI evaluated the full CHT cost for that period and determined a return on investment of $2.85 for each dollar spent.
  • The University of Rhode Island conducted an analysis on data collected from seven CHTs across four different sites. The study found statistically significant reductions in health risk, depression, anxiety, substance use, patient-reported “unhealthy days,” and a variety of health-related social needs among CHT-participating patients. Survey results also suggest positive patient experience with CHT care.
  • A study published in The American Journal of Managed Care examined data from Thundermist Health Center patients. This analysis found that the CHT program led to statistically significant reductions in hospitalizations and inpatient costs. Additionally, differential impacts were observed based on level of patient interactions with CHTs. For example, patients in the low encounter subgroup showed statistically significant reduction in total cost of care while patients in the high encounter subgroup showed increased total cost of care. This suggests that CHTs may have been able to more quickly address needs of their less complex patients.


Standardized guidance and sharing best practices among stakeholders can be helpful to support implementation.

A key finding from early provider experiences with CHT implementation was more structure and guidance on aspects of the CHT model such as care teams, workflows, and tools for identifying patients was needed to support implementation and help scale the model. For example, developing standard processes for CHTs (e.g., intake, treatment, and discharge) is helpful in guiding staff in how to manage a multitude of complex situations and ensure care is goal-directed. Having a convener (i.e., CTC-RI) that could bring multiple stakeholders together was helpful in working toward shared goals, including through spreading lessons and best practices among providers.

CHW work is challenging and providing appropriate organizational support is key.

There are many aspects of CHW roles that can be uniquely challenging. For example, CHWs are tasked with working to address a wide range of barriers to care and progress can often be slow. By nature, CHWs’ work in home- and community-based settings also means they often work separate from other team members. It is important to consider how to best support CHWs in their work such as through training on boundary setting and how to handle complex situations, having accessible supervisors who can help trouble shoot ad-hoc issues, and having team or even cross-team meetings to work through cases and share lessons.

Fee-for-service has limitations and there may be opportunities to explore alternative payment approaches for multidisciplinary, community-based care.

While the program financing model is still in transition, implementors expect some inherent challenges with fee-for-service (FFS) payment for the CHT model. For example, FFS payment does not cover all costs of the community-based work CHWs and BH clinicians do and can be administratively burdensome. Alternative approaches, such as per member per month payment for a broad set of activities, may allow more flexibility to support the model. Multi-payer alignment is also important for sustainable payment levels. For instance, Vermont’s community health teams are supported through per-member per-months payments funded by Medicare, Medicaid, and commercial payers.

Data and evaluation are important for building the case for sustainability.

Early on, Rhode Island stakeholders recognized the need for evaluation and committed to collecting a wide range of data (e.g., on behavioral health screenings, social needs screenings, qualitative feedback from patients and providers, etc.). While administratively taxing, this focus on measurement helped demonstrate the wide impact of CHTs and secure funding for the model.


Thank you to the following individuals who helped inform this profile:

  • Linda Cabral, Debra Hurwitz, Michelle Mooney, and Pano Yeracaris, Care Transformation Collaborative Rhode Island
  • Elizabeth Fortin and Kylie Zoglio, South County Health
  • Jennifer Pace, Matthew Roman, and Gloria Rose, Thundermist Health Center
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