Community Health Team

Aesculapius Medical Center, Vermont

Community Health Team at Fletcher Allen

Fletcher Allen’s patient-centered medical homes are primary care settings that improve quality and educate patients, empowering them to become partners in their care to create optimum health.

Patient-Centered Medical Homes include Community Health Teams - nurses, social workers, dietitians and health educators, who work together to help you manage your condition.

The Community Health Team provides a number of services, including:

  • Conducting health screening assessments
  • Helping you manage your medications
  • Connecting you with community/financial resources

Getting Results

In 2011, patients cared for by a Community Health Team experienced a 22.5% decrease in hospital admissions and 33.7% decrease in Emergency Department admissions.

Six months after leaving the Community Health Team, 60% of diabetes patients maintained weight loss, and 54.2% of diabetes patients improved their cholesterol.

Background

Fletcher Allen’s Patient-Centered Medical Homes and Community Health Teams are an outgrowth of the Vermont Blueprint for Health, a statewide partnership to move health care to a system focused on preventing illness and complications.

Fletcher Allen has served as one of three pilot sites for the Blueprint for Health and a leader in Vermont in designing community health teams.  We are currently expanding this model of care to a number of primary care practices around the state.

Community Health Team Services

Meet the Community Health Team

A patient-centered medical home fosters a team approach to improving health outcomes for patients. The Community Health Team is a group of professionals on the team who will give you the tools and support you need to reach your goals.

The members of the Community Health Team provide multidisciplinary expertise in helping you manage your chronic condition. Each member brings a level of expertise in different areas to help you be as healthy as possible.

Our nurses will:

  • Conduct a health assessment and screening.
  • Work with you to develop strategies to manage your condition.
  • Help you manage your medications.
  • Provide diabetes education.
  • Provide guidance for healthier living.
  • Help you set goals to improve your health.
  • Provide coaching to help you meet your goals.

Our Health Educator will:

  • Conduct a health assessment and screening.
  • Work with you to provide guidance and tools for healthier living, such as keeping a food log, and understanding nutrition labels.
  • Work with you to develop strategies to manage your condition.
  • Help you set goals to improve your health.
  • Provide coaching to help you meet your goals.

Our Community Resource Social Worker will:

  • Conduct a health assessment and screening.
  • Connect you with community/financial resources.
  • Assist you or a loved one with long-term care planning.
  • Partner with other agencies to coordinate care.
  • Help you set goals to improve your health.
  • Provide coaching to help you meet your goals.

Our Behavioral Health Social Worker will:

  • Conduct a health assessment and screening.
  • Help you identify barriers to meeting your health care goals.
  • Help you with coping, relaxation and self-care strategies.
  • Help you manage symptoms of anxiety and depression.
  • Provide coaching to help you meet your goals.

A certified dietician will:

  • Review your health assessment and screening results.
  • Provide diabetes education.
  • Provide nutrition information for specific health conditions.

In addition, the Community Health Team will, if appropriate, connect you with an exercise program at the YMCA, which has facilities in Burlington and Winooski. You will receive a program tailored to your needs and you will work with YMCA-certified personal trainers in small, one-hour fitness trainings.

Fletcher Allen Clinics

Private Practice Clinics

Fletcher Allen helped expand the medical home model to the following private practice clinics by providing project management support and, in some cases, helping them through the patient-centered medical home recognition process.


Ask your provider if a referral to the community health team is right for you.

Community Agency Provider Referral Form

This referral form is for Fletcher Allen's community partners that have worked with our Community Health Team (CHT) and have a client that might benefit from the services of the CHT. The Community Health Team will inform the client’s primary care provider and we will let you know how we will proceed. 

If you have questions, please contact us at 802-847-1601.

Please download and fill out the form and return it via email to cht@vtmednet.org or send via fax or postal mail to:

Community Health Team
Fletcher Allen Health Care
128 Lakeside Ave, Suite 106
Burlington, VT 05401
Phone: (802) 847-1601
Fax: (802) 847-6545


Related Documents

Community Agency Provider Referral Form Download PDF


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