1. Community Care Teams and the Patient-Centered Medical Home (PCMH) model can be enhanced by including mental health and substance use services and care coordination to create a Person-Centered Healthcare Home (PCHH). 2. Community Care of North Carolina uses Community Care Networks (CCNs) that are public-private partnerships providing coordinated care through medical homes. Preliminary results show improved care for patients with chronic conditions and cost savings. 3. CCNs employ care managers who work with medical homes to coordinate care for high-risk patients through activities like patient education and addressing barriers to care.