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CTC CHT Services and Resources


Community Health Team Newsletters: 

March 2021 Newsletter 

March 2020 Newsletter 

December 2019 Newsletter 



Community Health Team Video (1)

Brown Family Medicine’s Partnership with CTC-RI’s Community Health Team- Family Service of RI Video

Community Health Team Map

COVID-19 Relief Funds Infographic

Community Health Team Hybrid Model May 2021

Summary of COVID-19 Related Supports Provided by Community Health Teams

FY 21 Annual Data 

CHT BCBSRI NCM Presentation 10.5.21

CHT Business Case 10.22.21


Building Community Clinical Linkages Series: 

December 4, 2020- Part 1 

January 22, 2021- Part 2

February 26, 2021- Part 3 


Family Care Liaison:

As care coordinators, you may need help to identify resources to address child and family needs. The Family Care Liaison is a new resource for care coordinators and nurse care managers at PCMH-Kids practices.

What can the Family Care Liaison do?

The Family Care Liaison will assess the needs and eligibility of the child or children and identify and coordinate with appropriate programs to meet their needs

  • Enhanced care coordination through RIPIN’s Cedar Family Center
  • School supports from RIPIN’s special education experts
  • Family support from RIPIN Peer Professionals
  • Other relevant programs, both inside and outside RIPIN

RIPIN's new Family Care Liaison can help any family with a child

  • In need of in-home services
  • Whose family is at risk for food or housing insecurity
  • Whose parent presents as overwhelmed with their child's needs
  • Whose family is affected by Substance Use Disorder (SUD) or at risk for Opiate Use Disorder (OUD)


RIPIN- Family Care Liaison


Multidisciplinary Family Care Team:

The goal of this collaboration is to pilot a cross-agency, cross-discipline, intentionally-designed team approach to serve families (children and adults) with complex medical, behavioral and social needs. The intention is for this pilot to specifically serve families affected by Substance Use Disorder (SUD) or at risk for Opiate Use Disorder (OUD). The Family Care Team brings together people from the different agencies and programs families are working with in order to facilitate information sharing and provide more streamlined support.  This includes representatives from the client’s Family Home Visiting team and Community Health Team (CHT).

Family Care Team meetings happen weekly.  During these meetings, information is shared about the family needs, referrals made, and progress made towards achieving goals. Gaps are identified and action steps are outlined.  Having representatives from the key agencies involved in providing family support is essential to the success of this pilot.  Families are invited to participate in these meetings.

 Patient Benefits
  • Improved overall patient and family care
  • Decreased gaps in care
  • Improved service coordination
  • Expedited referral process
  • Improved care planning
Staff Benefits
  • Streamlined treatment pathways and reduction in duplication of services
  • Improved collaboration and communication between providers
  • Increased educational opportunities
  • Ability to share and learn about valuable community resources
  • Decreased staff burnout through collegiate support


MDT Pilot One Pager


Our Mission

The mission of CTC-RI is to support the continuing transformation of primary care in Rhode Island as the foundation of an ever-improving integrated, accessible, affordable, and equitable health care system.  CTC-RI brings together critical stakeholders to implement, evaluate and spread effective multi-payer models to deliver, pay for and sustain high-quality, comprehensive, accountable primary care.