Rutland Regional’s Blueprint for Health Community Health Team
As Vermont’s second largest hospital, and largest community hospital, Rutland Regional Medical Center has a key leadership role in implementing the Vermont Blueprint for Health for the hospital’s service area. The Community Health Team (CHT), an integral part of the Blueprint, is coordinated and supported by Rutland Regional and is actively working with patients in Blueprint practices. The CHT goal is to coordinate care across multiple health related organizations to help patients at home, in the doctor’s office, and during transition between care sites.
The Community Health Team has staff from multiple organizations, with positions in the community supported by funds from the state, federal government and health insurers. The core CHT staff at Rutland Regional Medical Center includes:
- Community Health Team Manager
- RN and MSW Case Managers
- Tobacco Cessation Counselors
- Asthma Educator
- Registered Dietitian
- Healthier Living Workshop Coordinator
- Care Coordinators for Opiate Addiction
- Health Coaches
- Advance Directive Explainers
The extended CHT includes these staff from other organizations:
- Medicaid Case Managers
- SASH Care Coordinators (Support and Services at Home)
- SASH Wellness Nurse
- Primary Care Practice Panel Managers
- Primary Care Practice Care Coordinators
Future plans include:
- Increase the number of primary care providers participating in the Blueprint
- Provide additional self-management support programs
Important initiatives supported or implemented by the Community Health Team include:
- Panel Management. A process to identify and then address patient care needs within a primary care practice fulfilled by panel managers.
- Transitions of Care. Targeted toward reducing readmissions of all patients, this program will start by focusing on reducing the number of patients discharged with a diagnosis of CHF from being readmitted within 30 days. The program will also be applied to other chronic conditions.
- Care Coordination. Making sure the needs of the patient are identified and met through a care coordinator that supports their primary care physician.
- Self-Management Support Programs. These evidence based programs help participants take charge of their health and make lifestyle adjustment to improve or maintain health.
- Health Coaching. Individualized or group support that leads to improved self-management of any disease process by the patient. This includes referral to existing resources such as Healthier Living Workshops, Bone Builders, Tobacco Cessation, etc.
- Prevention at a Community Level. Working with government and community partners to assure that our communities encourage bike and walking paths, nutritious food choices at the corner market and smoke-free venues to name a few items.
Rutland Area Community Resource Guide
The Rutland Area Community Resource Guide is a collection of health and human services available to the Rutland Area. This collective guide has been created and provided by the Rutland Regional's Blueprint Community Health Team.
To request a printed copy of the Rutland Community Resource Guide or to request changes or updates, please call 802.773.9888, ext. 10.