By Wendy Cornwell, RN

Over three years ago, Brattleboro Memorial Hospital joined the Vermont Blueprint for Health, a state-wide initiative designed to transform health care delivery and empower patients. The effort began with the recognition that improving patient health required a team-orientated approach, improved management of chronic conditions, and increased access to care.

Crucial to these efforts are Patient-Centered Medical Homes (PCMH) and the Community Health Team (CHT). Patient-Centered Medical Homes are primary care practices certified by the National Committee of Quality Assurance (NCQA). This certification means that these medical practices have met rigorous standards for providing quality patient care. The standards include increased access for same day appointments, utilization of electronic medical records to reduce fragmentation of care, and outreach to patients needing preventative screenings or visits.

Wendy Cornwell
Wendy Cornwell

The Community Health Team works closely with the medical homes, helping patients manage their chronic diseases and improve their level of health. The Community Health Team services are free of charge to all patients in a PCMH practice. The Brattleboro CHT is made up of a team of eleven providers. These include: project manager for the VT Blueprint for Health, care coordinator, medical assistant, Vermont Health Connect Navigator, project coordinator, Self-Management Program Coordinator, social worker, dietitian, health coach, diabetes educator, and nutritionist.

In order to be eligible for services of the CHT a person has to either be enrolled in the SASH (Support and Services at Home) program or be a patient of one of the certified medical home practices. These practices include the following BMH Physician Group Practices: Brattleboro Family Medicine, Brattleboro Internal Medicine, Putney Family Healthcare, Windham Family Practice and will soon welcome Maplewood Family Practice. Additionally, Brattleboro Primary Care and HeartSong for Health are also PCMH certified.

The Community Health Team’s services are provided at no cost to patients and the team works with people as long as they are committed to health improvement. Services include help with accessing state and local services and benefits, medication management, care planning, weight loss and nutrition counseling, short-term behavioral health therapy, and diabetes management.

The CHT program is patient-focused, meaning that services are individualized to meet each patient’s needs. Community Health Team members make home visits when appropriate and assist with most age related and chronic disease problems that people face. The CHT also works with pediatric populations and their families.

Most recently, the Vermont Blueprint has begun an effort to help patients with opioid addiction. The program, called the Hub and Spoke, creates a partnership between clinicians and addiction treatment centers. The ‘Hub,’ or regional opioid treatment centers, manages complex addictions. The ‘Spoke’ consists of a team of outpatient physicians, clinician case managers, and RNs who work closely with patients receiving medication-assisted therapy to provide treatment, care coordination, and facilitate recovery. The ‘Spoke’ team closely collaborates with the Community Health Team for patients working to overcome opioid addiction.

As more physician practices commit to becoming NCQA certified, the future plan for the Community Health Team is to expand the number of team members serving the Brattleboro Memorial Hospital service area. The mission of the Community Health Team is to partner with patients to improve their ability to manage their health conditions and their overall quality of life.

Wendy Cornwell, RN is the Director of Community Initiatives and the Brattleboro Project Manager for Vermont Blueprint for Health. She can be reached at 802-257-8325.

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