---
kind: "section"
citation: "42 U.S.C. § 256a–1"
title: "42"
title_heading: "The Public Health and Welfare"
number: "256a–1"
heading: "Establishing community health teams to support the patient-centered medical home"
release: "119-102"
url: "https://uscodex.org/usc/42/256a-1"
units:
  - "Chapter 6A — Public Health Service"
  - "Subchapter II — General Powers and Duties"
  - "Part D — Primary Health Care"
  - "Subpart v — healthy communities access program"
---

# §256a–1. Establishing community health teams to support the patient-centered medical home

- (a) **In general—** The [Secretary](/usc/42/201.md?p=c) of Health and Human [Services](/usc/42/201.md?p=a) (referred to in this section as the “[Secretary](/usc/42/201.md?p=c)”) shall establish a [program](/usc/42/274l–1.md?p=4) to provide grants to or enter into contracts with [eligible entities](/usc/42/296.md?p=1) to establish community-based interdisciplinary, interprofessional teams (referred to in this section as “[health teams](/usc/42/1396w–4.md?p=h-7)”) to support [primary care](#f) [practices](/usc/42/17061.md?p=19), including obstetrics and gynecology [practices](/usc/42/17061.md?p=19), within the [hospital](/usc/42/1395dd.md?p=e-5) [service](/usc/42/201.md?p=a) areas served by the [eligible entities](/usc/42/296.md?p=1). Grants or contracts shall be used to—
  - (1) establish [health teams](/usc/42/1396w–4.md?p=h-7) to provide support [services](/usc/42/201.md?p=a) to [primary care](#f) providers; and
  - (2) provide capitated payments to [primary care](#f) providers as determined by the [Secretary](/usc/42/201.md?p=c).
- (b) **Eligible entities—** To be eligible to receive a grant or contract under [subsection (a)](#a), an entity shall—
  - (1)
    - (A) be a [State](/usc/42/300gg–91.md?p=d-14) or [State](/usc/42/300gg–91.md?p=d-14)-designated entity; or
    - (B) be an [Indian tribe](/usc/42/300f.md?p=14) or [tribal organization](/usc/42/629a.md?p=a-6), as defined in [section 1603 of title 25](/usc/25/1603.md);
  - (2) submit a plan for achieving long-term financial sustainability within 3 years;
  - (3) submit a plan for incorporating prevention [initiatives](/usc/42/19131.md?p=1) and patient education and care management resources into the delivery of health care that is integrated with community-based prevention and [treatment](/usc/42/11851.md?p=11) resources, where available;
  - (4) ensure that the [health team](/usc/42/1396w–4.md?p=h-7) established by the entity includes an interdisciplinary, interprofessional team of [health care providers](/usc/42/300jj.md?p=3), as determined by the [Secretary](/usc/42/201.md?p=c); such team may include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and [treatment](/usc/42/11851.md?p=11) providers), doctors of chiropractic, licensed complementary and alternative medicine [practitioners](/usc/42/1395a.md?p=b-6-C), and [physicians](/usc/42/1395cc–4.md?p=a-2-E)’ assistants;
  - (5) agree to provide [services](/usc/42/201.md?p=a) to [eligible individuals](/usc/42/239.md?p=a-6) with chronic conditions, as described in [section 1396w–4 of this title](/usc/42/1396w–4.md) (as added by [section 2703](/usc/42/2703.md)), in accordance with the payment methodology established under [subsection (c)](/usc/42/2703.md) of such section; and
  - (6) submit to the [Secretary](/usc/42/201.md?p=c) an application at such time, in such manner, and containing such information as the [Secretary](/usc/42/201.md?p=c) may require.
- (c) **Requirements for health teams—** A [health team](/usc/42/1396w–4.md?p=h-7) established pursuant to a grant or contract under [subsection (a)](#a) shall—
  - (1) establish contractual [agreements](/usc/42/1320b–8.md?p=a-3-A) with [primary care](#f) providers to provide support [services](/usc/42/201.md?p=a);
  - (2) support patient-centered medical homes, defined as a mode of care that includes—
    - (A) personal [physicians](/usc/42/1395cc–4.md?p=a-2-E) or other [primary care](#f) providers;
    - (B) whole [person](/usc/42/1320a–7k.md?p=d-4-C-i) orientation;
    - (C) coordinated and integrated care;
    - (D) safe and high-quality care through evidence-informed medicine, appropriate use of [health information](/usc/42/300jj.md?p=4) technology, and continuous quality improvements;
    - (E) expanded access to care; and
    - (F) payment that recognizes added value from additional components of patient-centered care;
  - (3) collaborate with local [primary care](#f) providers and existing [State](/usc/42/300gg–91.md?p=d-14) and [community based](/usc/42/11851.md?p=1) resources to coordinate disease prevention, chronic disease management, transitioning between [health care providers](/usc/42/300jj.md?p=3) and settings and case management for patients, including [children](/usc/42/256e.md?p=g-2), with priority given to those amenable to prevention and with chronic diseases or conditions identified by the [Secretary](/usc/42/201.md?p=c);
  - (4) in collaboration with local [health care providers](/usc/42/300jj.md?p=3), develop and implement interdisciplinary, interprofessional care plans that integrate clinical and community preventive and health promotion [services](/usc/42/201.md?p=a) for patients, including [children](/usc/42/256e.md?p=g-2), with a priority given to those amenable to prevention and with chronic diseases or conditions identified by the [Secretary](/usc/42/201.md?p=c);
  - (5) incorporate [health care providers](/usc/42/300jj.md?p=3), patients, caregivers, and authorized [representatives](/usc/42/3058f.md?p=5) in [program](/usc/42/274l–1.md?p=4) design and oversight;
  - (6) provide support necessary for local [primary care](#f) providers to—
    - (A) coordinate and provide access to high-quality health care [services](/usc/42/201.md?p=a);
    - (B) coordinate and provide access to preventive and health promotion [services](/usc/42/201.md?p=a);
    - (C) provide access to appropriate specialty care and inpatient [services](/usc/42/201.md?p=a);
    - (D) provide quality-driven, [cost-effective](/usc/42/1396e.md?p=e-2), culturally appropriate, and patient- and [family](/usc/42/290ff–4.md?p=d-2)-centered health care;
    - (E) provide access to pharmacist-delivered medication management [services](/usc/42/201.md?p=a), including medication reconciliation;
    - (F) provide coordination of the appropriate use of complementary and alternative (CAM) [services](/usc/42/201.md?p=a) to those who request such [services](/usc/42/201.md?p=a);
    - (G) promote effective strategies for [treatment](/usc/42/11851.md?p=11) planning, monitoring health outcomes and resource use, sharing information, [treatment](/usc/42/11851.md?p=11) decision support, and organizing care to avoid duplication of [service](/usc/42/201.md?p=a) and other medical management approaches intended to improve quality and value of health care [services](/usc/42/201.md?p=a);
    - (H) provide local access to the continuum of health care [services](/usc/42/201.md?p=a) in the most appropriate setting, including access to individuals that implement the care plans of patients and coordinate care, such as integrative health care [practitioners](/usc/42/1395a.md?p=b-6-C);
    - (I) collect and report data that permits evaluation of the success of the collaborative effort on patient outcomes, including collection of data on patient experience of care, and identification of areas for improvement; and
    - (J) establish a coordinated system of early identification and referral for [children](/usc/42/256e.md?p=g-2) at risk for developmental or behavioral problems such as through the use of infolines, [health information](/usc/42/300jj.md?p=4) technology, or other means as determined by the [Secretary](/usc/42/201.md?p=c);
  - (7) provide 24-hour care management and support during transitions in care settings including—
    - (A) a transitional care [program](/usc/42/274l–1.md?p=4) that provides onsite visits from the care coordinator,[^1] assists with the development of discharge plans and medication reconciliation upon admission to and discharge from the [hospitals](/usc/42/1395dd.md?p=e-5),[^2] [nursing home](/usc/42/1396g.md?p=e-1), or other institution setting;
    - (B) discharge planning and counseling support to providers, patients, caregivers, and authorized [representatives](/usc/42/3058f.md?p=5);
    - (C) assuring that post-discharge care plans include medication management, as appropriate;
    - (D) referrals for mental and behavioral health [services](/usc/42/201.md?p=a), which may include the use of infolines; and
    - (E) transitional health care needs from adolescence to adulthood;
  - (8) serve as a liaison to community prevention and [treatment](/usc/42/11851.md?p=11) [programs](/usc/42/274l–1.md?p=4);
  - (9) demonstrate a capacity to implement and maintain [health information](/usc/42/300jj.md?p=4) technology that meets the requirements of [certified EHR technology](/usc/42/300jj.md?p=1) (as defined in [section 300jj of this title](/usc/42/300jj.md)) to facilitate coordination among members of the applicable care team and affiliated [primary care](#f) [practices](/usc/42/17061.md?p=19); and
  - (10) where applicable, report to the [Secretary](/usc/42/201.md?p=c) information on quality measures used under [section 280j–2 of this title](/usc/42/280j–2.md).
- (d) **Requirement for primary care providers—** A provider who contracts with a care team shall—
  - (1) provide a care plan to the care team for each patient [participant](/usc/42/300gg–91.md?p=d-11);
  - (2) provide access to [participant](/usc/42/300gg–91.md?p=d-11) health records; and
  - (3) meet regularly with the care team to ensure integration of care.
- (e) **Reporting to Secretary—** An entity that receives a grant or contract under [subsection (a)](#a) shall submit to the [Secretary](/usc/42/201.md?p=c) a report that describes and evaluates, as requested by the [Secretary](/usc/42/201.md?p=c), the activities carried out by the entity under [subsection (c)](#c).
- (f) **Definition of primary care—** In this section, the term “primary care” means the provision of integrated, accessible health care [services](/usc/42/201.md?p=a) by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of [family](/usc/42/290ff–4.md?p=d-2) and community.

## Footnotes

[^1]: So in original. The comma probably should be “and”.
[^2]: So in original. Probably should be “hospital,”.

## Source credit

(Pub. L. 111–148, title III, § 3502, title X, § 10321, Mar. 23, 2010, 124 Stat. 513, 952.)

## Notes

### Editorial Notes

### References in Text

Section 2703, referred to in subsec. (b)(5), means section 2703 of Pub. L. 111–148.

### Codification

Section was enacted as part of the Patient Protection and Affordable Care Act, and not as part of the Public Health Service Act which comprises this chapter.

### Amendments

2010—Subsec. (c)(2)(A). Pub. L. 111–148, § 10321, inserted “or other primary care providers” after “physicians”.