CHSLV’s Community Health Team can help patients navigate the health care system, utilize community services, find affordable prescriptions, and assist in managing chronic medical conditions. But what, exactly, is CHSLV’s Community Health Team?
The Community Health Team, or CHT of CHSLV, is funded by the Blueprint for Health initiative. The team can provide free assistance to CHSLV patients. Your primary care practitioner and the CHT work together as a team to help you get the most support from your visit and beyond. The team consists of care coordinators and case managers that are registered nurses, registered dietitians, certified diabetes educators, and social workers. The team also has a coordinator for self- management classes. In addition to your primary care physician (PCP) visit, CHT provides education about chronic conditions and works with patients in making healthy lifestyle changes by supporting them in setting realistic goals. Care coordinators and case managers can also help with other pressing needs, such as completing financial assistance applications for services, applying for health insurance, connecting to transportation services, finding affordable medications and housing, and much more.
The team can assess problems in areas that affect your health and help you and your family get the resources and support that is needed to improve your health. Additionally, they can provide tobacco treatment and healthy living workshops and one-on-one healthy living guidance. CHT care coordinators, case managers, and the coordinator for self- management classes can help patients sign up for various free programs such as the Diabetes Prevention Program; Healthier Living Workshops for Chronic Conditions, Diabetes, and Chronic Pain; and Smoking Cessation.
1) Your PCP introduces you to the CHT when a need is identified during your PCP visit. This face-to-face meeting during the visit is called a “warm hand off.”
2) Your PCP makes a referral to the CHT and you will receive a call very shortly after the referral.
3) You ask your PCP for a referral to the CHT for one or more services that they provide.
4) You or a family member calls the practice and asks to speak to a CHT staff member.
CHSLV’s CHT is connected to numerous social health services in Lamoille County. They share resources and knowledge, and deal with any health care barriers. The CHTs in Lamoille County include representatives from Copley Hospital, Copley Wellness, Lamoille Home Health and Hospice, the Manor, Council on Aging, Support and Services at Home (SASH), Vermont Department of Health Access, Lamoille County Mental Health, Lamoille Family Center, care coordinators from other local medical homes, Clarina Howard Nichols Center, The Recovery Center and many others. They all work together to improve the health of the community and provide a source of referrals for patients. These organizations also make up the Lamoille County Care Management Team, a group of community organizations who work together with individuals to navigate complex healthcare needs. Please ask your PCP if a CHT referral is right for you?