News Release

Grant will support Waterbury community care team sustainability

Connecticut Health Foundation awards two grants this quarter

HARTFORD, Conn. (April 5, 2022) – With a $100,000 grant from the Connecticut Health Foundation, Greater Waterbury Health Partnership plans to expand its community care team, which brings together health care and social service providers to meet the needs of patients who frequently visit the emergency department.

The project began in 2019 with funding from the foundation as part of an initiative to better link clinical care with community-based services that can play a significant role in people’s health. An analysis found that in a one-year timeframe, the intense interventions of the community care team helped 21 patients avoid 153 hospitalizations, saving $1.3 million in total health care costs. The program is currently serving 32 patients and expects to report additional positive outcomes this summer from a second year.

Greater Waterbury Health Partnership now plans to expand the community care team to serve more patients and will work to secure sustainable funding for the team’s work, potentially by having clinical partners reinvest a percentage of the cost savings.

Many of the community care team’s patients face challenges including mental health or substance use issues, homelessness, and housing instability. While going to the emergency department can address acute health needs, clinical care providers don’t typically have the tools to help patients with significant non-medical challenges that often contribute to or worsen their medical needs, such as unstable housing. The community care team aims to better meet the needs of patients by bringing together and coordinating health care, social service, and other providers, who can work together to better meet both clinical and social needs.

The Waterbury community care team includes representatives from 17 organizations, including Staywell Health Center, New Opportunities Inc., Center for Human Development, as well as state agencies, housing and homeless service providers, mental health care services, and opioid response providers. The community care team has helped patients move into housing, enroll in Medicaid or other forms of insurance coverage, receive disability benefits, and address health conditions including diabetes, congestive heart failure, and mental health needs.

While many community care teams exist nationally, it has been challenging to find sustainable funding to support the work, in part because it’s difficult to collect and report outcomes data to demonstrate effectiveness and cost-savings. Greater Waterbury Health Partnership uses a database, Unite Us, to track when patients are referred to partners for services, and conducts additional data analysis with hospitals’ data on the community care team’s patients. This allows the organization to compare hospital visits before and during the intervention to identify avoided hospitalizations and cost savings. In addition to supporting the community care team’s planning, operations, and case management services, funding from the Connecticut Health Foundation has supported data collection and reporting and financial analysis. Greater Waterbury Health Partnership is now building the capacity to continue this work internally.

“The Waterbury community care team has shown the value of partnerships and strong relationships in better serving patients,” Connecticut Health Foundation President and CEO Tiffany Donelson said. “Going forward, it will be critical to find ways to ensure that our health care system rewards the work that best meets people’s needs in a holistic way, rather than only compensating providers based on medical visits. This kind of approach, focused on relationships, holistic coordinated care, and truly meeting people’s needs, is critical to achieving health equity.”

“The community care team’s clients are among the most vulnerable of the community, each with their own unique story, trauma, and struggles,” Greater Waterbury Health Partnership Executive Director Angie Matthis said. “The true measure of success is in the stabilization and improved quality of life for our clients. Our goal now is to find ways to assure that this work can be sustainably funded so we can continue this life-saving work.”

This grant was one of two awarded this quarter. The other is:

Connecticut Oral Health Initiative, Hartford: $85,000

This funding will support the Connecticut Oral Health Initiative, or COHI, in its work to improve access to dental care for adults covered by Medicaid. In interviews and focus groups, Connecticut residents covered by Medicaid reported difficulty getting timely, quality dental services, for both routine and specialty care. To address this, COHI plans to advocate for changes to increase the number of providers available to treat adults with Medicaid coverage, with strategies including increasing Medicaid payment rates and developing a workforce of dental therapists who could provide routine oral health care.

For more information, please contact Arielle Levin Becker at or 203-901-2363.