Community Health Teams and Their Maturing Impact on Chronic Illness

| Graceful Health

By Bill Monahan, RN, Grace Cottage Outreach Coordinator

Blueprint for Health? Community Health Team (CHT)?

What are these, and how can they help you for free?

The Vermont Blueprint for Health was conceived in 2003 during Governor Douglas’s administration and implemented in 2010. The goal of Blueprint is better coordination of patient care for individuals, better health for the whole community, and reduced health care costs.

This nationally recognized, multi-faceted program includes a system of Community Health Teams (CHTs). There are fourteen CHTs in the state of Vermont, all subsidized by private insurers, Medicare, and grants, so that their services are offered to the community free of charge. Each team adapts its services to the needs of its particular service area.

When a primary care provider identifies that a patients needs additional support, beyond what can be provided during an office visit, that provider can refer the patient to the CHT, thus connecting patients to additional resources.

CHT services include individual appointments to assess a patient’s needs, ongoing help with understanding and following a provider’s recommendations, assistance with referrals, short-term counseling, substance abuse treatment and support, health coaching, and education and support for dealing with a specific chronic illness, like diabetes and hypertension.

The Grace Cottage Family Health CHT has eight members, who primarily work with patients who live in towns along the West River Valley, and other towns near Townshend, VT, where Grace Cottage is located. A Resource Advocate at Grace Cottage helps clients overcome an assortment of barriers to health, such as lack of food, health insurance, fuel assistance and housing.

Patients may be referred to the CHT by their medical providers, or they may make their own appointments without a referral. These services are offered at no charge. To contact Grace Cottage’s CHT, call 365-3715.

CHT programs can directly and indirectly improve health outcomes for individuals and communities.

Examples of direct intervention include the development of individualized plans to help patients make their homes safer, to remember to take medications on schedule, to practice self-care strategies like foot and skin care for diabetics, to stop smoking, to lose weight, or to transition from a hospital stay to home.

CHTs also help the general population by offering support groups, giving talks on health topics, and helping to connect people to resources such as affordable housing assistance, free food giveaways (thanks to the Vermont Food Bank and local food shelves), reduced fee and free dental care, subsidized utilities, and more. Grace Cottage also has a group of volunteer drivers who help patients get to appointments; this service is supported by the Fanny Holt Ames and Edna Louise Holt Fund.

The Vermont Blueprint for Health is less than a decade old and has taken firm root in Vermont’s primary care model. It is maturing in many ways.

The Blueprint’s aim is to connect Vermonters with whole-person health care. For patients with the most complex needs, the CHTs are interdisciplinary care teams that can help to deliver integrated care.

CHTs tend to serve people who are dealing with a chronic disease and need better access to care management and preventive services. When a CHT works with a patient, the situation may be complex, with a variety of challenges to be overcome. CHTs help patients understand these separate challenges and help them explore what they need to be healthy.

In addition to providing services directly to patients, CHTs support communities in addressing the root causes of poor health and gaps in care. CHT members work with other local organizations, representing the needs of patients they interact with every day.

CHTs combine the expertise of individual team members and a growing understanding of the gaps in the current health care system. The World Health Organization describes the social determinates of health as, “The circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” Knowing this, CHTs have shown a maturing approach to their impact on the social determinates of health.

For more information on the services of the Grace Cottage Community Health Team, visit the Grace Cottage website.

Bill Monahan, RN, is Grace Cottage’s Community Health Team Outreach Coordinator. He received his Associate’s degree in Liberal Studies from Berkshire Community College, his Associate’s in Nursing from Greenfield Community College, and his Bachelor’s in Health Advocacy from UMass-Amherst.