Care Coordination Collaborative (CCC) AIM

Over the period of the collaborative, primary care, mental health, substance use disorder, and other safety net providers, working with local public safety net health plans, will improve the coordination of care and social supports for individuals with chronic physical conditions and serious mental health, including those with co-occurring substance use disorders.  This coordination will result in a seamless experience of care that is person-centered, cost effective, and results in improved health and wellness.


  • The Model for Improvement which provides a process to improve the quality of care at an accelerated pace
  • Access to a diverse group of faculty with expertise in strength-based client assessment, research informed and recovery oriented practices, and community engagement
  • Use of a clinical data system to support client and population improvement
  • Structured support and collaborative learning in completion of EQRO required Performance Improvement Projects (PIPs) 


  • Senior leader participation in monthly leadership calls and attendance at learning sessions
  • Small scale tests of change followed by implementation and system-wide spread of those changes that work
  • Monthly reporting, qualitative and quantitative, that documents the learning and improvement
  • Attendance at all Learning Sessions (total of 5 over the course of 16 months) and participation in twice-monthly team calls
  • Inclusion of direct service staff, peers, and family members on teams