Assessment of Team Based Care and Care Coordination

Dates: 2014-2015

State: New York

Client(s): Regional Primary Care Network (RPCN)

Services: Health Care & Public Health Planning, Training & Technical Assistance, Health Systems Transformation

Technical Expertise: Health Care Reform, Integrated Care Models, Population Health, Primary Care, Safety Net


Multiple initiatives and funding streams are encouraging the re-design of primary care such as Patient-Centered Medical Homes and behavioral health integration. These initiatives encourage and can support the funding of care coordination. However it can be difficult for a practice to navigate and develop a cohesive strategy and implementation plan for care coordination.

JSI supported the Utica Community Health Center (UCHC) in conducting a landscape analysis of best practices in care coordination as they relate to whole-person and patient-centered care. JSI assessed UCHC’s staffing roles and responsibilities as they compare to these best practices and provided recommendations on training and cost needs for care coordination staff moving forward. JSI conducted an analysis of best practices, key informant interviews with UCHC staff involved in care coordination, identified gaps, and gave specific recommendations for training of staff to enable implementation of care coordination best practices.

UCHC and JSI’s goal in this assessment was to understand UCHC’s current practices and priorities and pair them with an understanding of best practices locally and nationally to build a realistic and pragmatic plan for the organization to transform to high-performing team-based care.