Comprehensive Care Services
Commonwealth Care Alliance

Comprehensive Care Services

Commonwealth Community Care provides a full range of care and services.

  • Primary Care and Care Coordination

    Commonwealth Community Care (CCC) has developed a unique approach to primary care specialized for people with complex health needs and disabilities.

    Each patient has a primary care team, led by a nurse practitioner or physician assistant, focused on preventive care and prompt response to new conditions. The team actively coordinates all the services and care needed. Our care is consumer-directed, so patients and their family or support network are involved in developing a care plan that meets each individual’s needs and preferences.

    The Primary Care Team

    Each patient’s primary care team has wide experience in the care of people with complex health needs, physical disabilities, developmental disabilities, and behavioral health issues. Each care team may include, as needed:

    • Primary Care Physician
    • Nurse Practitioner or Physician
    • Social Worker
    • Health Outreach Worker
    • Behavioral Health Specialist
    • Physical or Occupational Therapist
    • Long-Term Services and Supports Coordinator
    • Durable Medical Equipment Coordination Team
    • Administrative Services Coordinator

    Home or Office Care

    Our clinicians provide care where the patient needs it – whether at home or in a day program, group residence, or other community setting. For patients who wish to receive office care, our care centers are designed to be welcoming. Exam rooms include hi-lo tables, a wheelchair scale, transfer equipment, and lifts to facilitate exams for people with physical disabilities. We will arrange for translators or communication assistance as needed.

  • Durable Medical Equipment (DME) and Rehabilitation Services

    CCC has over 20 years of experience managing durable medical equipment for people with physical disabilities. We understand the enormous importance of wheelchairs and other assistive technology and medical equipment to the health and independence of persons with disabilities. Our Durable Medical Equipment coordination team works closely with our rehab specialists and DME vendors to ensure that patients are able to use and maintain their equipment, and to assist them in accessing repair services.

    Our expertise includes:

    • Wheelchairs, including power chairs with sophisticated arrays of assistive technology
    • Pressure-alleviating mattresses
    • Lifts
    • Shower chairs
    • Respiratory equipment
    • Adaptive equipment and electronic aids to daily living

    Equipment evaluations include visits to the patient’s home and other locations where equipment will be used. All of our physical and occupational therapists are ATP-certified and have extensive experience in seating and equipment evaluation. Our rehab therapists will take the time to ensure a complete and accurate assessment of each patient’s needs, and make certain that planned equipment will fit the space before referring to a vendor. Therapists also participate in joint evaluations with equipment vendors or other therapists at seating clinics in the community.

  • Integrated Behavioral Health Services

    Stress, anxiety, mood disorders, substance abuse, and other serious behavioral health issues can intensify the health issues that people with disabilities must face. Disabling injuries often involve post-traumatic stress syndrome (PTSD) and trauma. All of these emotional and behavioral health issues can be disabling conditions on their own. To ensure that people with complex health conditions receive the holistic care they need, CCC has fully integrated behavioral health services into our primary care practice.

    Our behavioral health team provides assessment and diagnosis of behavioral health conditions, acting as a bridge to connect patients to therapists and ensuring that treatment is integrated with other health services. Therapists are carefully matched to each patient to ensure a good “fit,” and can accommodate those with physical disabilities through home visits.

    Importance of communication

    All of the behavioral health providers in our network participate in our unique approach, which emphasizes communication between specialist providers and the primary care team. In the event of serious episodes requiring inpatient care, our behavioral health and primary care teams continue to follow patients, consulting on the discharge plan and easing patients through the transition to home and recovery.

    The behavioral health team also provides coaching and education to CCC nurse practitioners and physician assistants, training them to recognize and respond to signs of behavioral health issues, and to support patients through medication management and coping skills.
  • Social Work Support

    Our team of social workers works closely with primary care providers to help with housing, family issues, and access to community services.

    A stable and supportive living arrangement and productive ways of dealing with stress and life challenges are central to maintaining good health. CCC patients work with our social work team to set goals for the future, resolve personal and family problems, and secure services to support a productive and independent life.

    When needed, the team assists with affordable and accessible housing. Social work-support team members can help with applications for MassHealth, Social Security benefits, Food Stamps, and other programs. They also make referrals for vocational and educational support.

  • Acute Care Collaboration

    ​In the event a patient needs hospitalization or acute care, the CCC primary care team ensures good communication with facility staff and helps with transitions to home or rehabilitation centers.

    The primary care team discusses decisions with each patient, and communicates with emergency room and hospital personnel to simplify admission and see to it that the patient’s needs are understood. The team will ensure that transitions between facilities and home reflect patient preferences, and that plans for follow-up appointments and medical and pharmaceutical regimens are clear.

    After discharge, our team members will check in with patients and their family or caregivers to make certain that patients are safe and settled in the recovery or care setting of their choice.

  • Life Choices Palliative Care

    The mission of Life Choices  is to honor the choices of patients and families for palliative end-of-life care. The Life Choices program is based on these core principles:

    • End-of-life care should be a normal part of our long-term primary care model, without interruption.
    • Conversations about goals of advanced care should be promoted within the primary care relationship, and should focus on discussion, not decision
    • Because we believe in respecting patients’ wishes, patients should have the right to refuse aggressive care
    • Home-based services should provide increased support for family caregivers and allow a death at home in keeping with a patient’s wishes
    • Community partners should be included in palliative care when appropriate and beneficial
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