The Interdisciplinary Team in the Care Transformation Organization

Timeslot: Tuesday, October 10, 2023 - 2:45 PM to 3:45 PM
Session Type: Concurrent Session


For purposes of the Maryland Primary Care Program (MDPCP) CMS defines a Care Transformation Organization (CTO) as “an entity that hires and manages an interdisciplinary care management team capable of furnishing an array of care coordination services to Maryland Medicare beneficiaries attributed to Participant Practices.” Our CTO is comprised of Social Work, RN Case Managers, Care Coordinators (non-clinical), Community Health Workers, and a Pharmacist. The interdisciplinary team works with the patient’s primary care provider and will coordinate services after assessing the patient’s Social Determinants of Health (SDoH), medical and social history.

The CTO team is embedded in our primary care offices and coordinates care in a variety of ways. The RN Case Managers provide chronic disease education and coordinate the overall plan of care. Community Health Workers are everything social from assessing SDoH and providing resources for those barriers such as transportation and food insecurity. Care coordinators provide pre-visit planning and set up appointments helping patients navigate through the continuum. Social work is our behavioral health connection as well as has the goals of care and long-term care planning discussions with patients and their families. Finally, our Pharmacist provides comprehensive medication review and consolidation as well as medication education and compliance discussion. Our whole team will meet with patients telephonically, in the provider’s office, at home, or even at a local diner.

The CTO has first-hand knowledge and experience of what patients are facing in their lives. Every day we see patients that have transportation barriers due to mobility, patients that don't qualify for government assistance because they make a few dollars too much, or basic needs for food and toiletries are not met. We come in to try to make a difference.

Learning Outcomes

  • Define a Care Transformation Organization (CTO) and how it benefits its beneficiaries

  • Understand how we meet patient needs through assessing SDoH, and medical needs and challenges

  • Describe how the CTO partners with community and organizational resources