North Central Region Community Care Team

North Central Region Community Care Team

Defining the Need

It is well known, and documented, that a very small portion of the homeless population incurs the majority of the costs to the public.  Similarly, a very small segment of those seeking healthcare services, over consume emergency and inpatient services in such a way that they make up a disproportionate share of expenses.  Those clients, that are frequent users of both the healthcare and homeless services system, make up an even greater disproportionate amount of system costs.  While people experiencing homelessness make up only 3% of the Medicaid population, they make-up 8% of overall Emergency Department visits and 12.5% of emergency department visits for those with behavioral health diagnoses.  Likewise, those who are homeless make up close to 20% of the Medicaid members with inpatient mental health stays and 27% of patients with three or more inpatient mental health stays in one year, according to data compiled by Beacon Health Options (formerly Value Options) looking at Medicaid claims data from 2011-2012.  The Community Care Team model was developed as a potential solution to the challenging issues of: 1) the disproportionate intersection of homelessness with emergency care and, 2) the disproportionate costs of this minority population to the system.

What is the NCRCCT?

The North Central Region Community Care Team (NCRCCT) is an expanding group of healthcare, human service, shelter and housing providers who meet regularly to case conference challenging client/patient cases.  Originally established in the Fall of 2014 as part of a larger, statewide effort, the NCRCCT was focused primarily on a data-driven population of frequent emergency department visitors who had a primary or secondary behavioral health diagnosis.  Since the original data-driven pilot ended, the NCRCCT has expanded its scope to include the discussion of any challenging patient who has complex, interrelated healthcare and/ or housing issues.

Preliminary data suggested that the majority of these identified frequent visitor patients were homeless, or at least faced housing instability. It quickly became apparent that many NCRCCT patients had identified stable housing as a goal.  The NCRCCT has embraced the idea that “housing is healthcare” and healthcare providers are working with the homeless services providers in unprecedented ways to identify housing options for mutual clients.

The mission of the North Central Region Community Care Team (NCRCCT) is to provide multidisciplinary and interagency coordinated care as it relates to the population of clients with complex behavioral health needs served by agencies in the north central region of Connecticut.

The NCRCCT operates around three goals that encapsulate this vision of coordinated care and of the unique needs of the NCRCCT’s clients.

I. Improve client connections to appropriate levels of care

By sharing resources and information, the NCRCCT’s members can increase their understanding of their clients’ needs and make better-informed treatment referrals and decisions. The connection between emergency treatment and community-based outpatient and preventative care is likewise strengthened and made more efficacious. 

II. Improve client health outcomes

By working together, the NCRCCT can direct its member agencies’ resources to best address its clients’ health needs. This is done by implementing consistent care plans that are collaboratively designed and executed by the NCRCCT.

III. Improve the stability of NCRCCT clients and connections to community resources

The NCRCCT’s care plans include both healthcare and social service components, such as case management services or housing navigation for the literally homeless. In this way, the NCRCCT treats health problems and fosters clients’ relationships with community-based supports.

Journey Home’s Role

In the fall of 2016, as a founding member, and a bridge between the healthcare field and shelter/housing sector, Journey Home offered to step in and provide administrative staffing for the NCRCCT.  As the entity that provides staffing for both the homeless crisis response system, the Greater Hartford Coordinated Access Network, and the NCRCCT, Journey Home is uniquely positioned to bridge the gap between these two sectors.

Recent funding from Well Being 360, a partnership between the St. Francis Hospital’s Curtis D. Robinson Center for Health Equity, the City of Hartford Department of Health and Human Services, and Community Solutions as part of Trinity Health effort called Transforming Community Initiative, has allowed Journey Home to continue on in this role and to proceed to an effort to assess the impact of the North Central Region CCT.

Questions regarding how to become a member agency, more information regarding the NCRCCT’s Release of Information, or any other questions may be directed to Amanda Gordon at Journey Home by calling (860) 808-0336 or emailing

Resources for Making CCT Referrals

North Central Region CCT Release of Information



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