The Community Health Team at BMH
We are a service established by Brattleboro Memorial Hospital
to help meet the goals set out in the Vermont Blueprint for Health.
The Community Health Team (CHT) is a group of skilled health care professionals who can help you understand and access the tools and supports you need to reach your personal health goals. Based on your individual needs, CHT staff members work with you to assess your situation, develop effective plans, and establish reachable goals that will move you in a positive direction.
CHT Provides Access to a Wide Range of Integrated Healthcare Services
When you receive care at one of our nationally-certified medical homes, you gain access to a wide range of integrated health care services. This is especially helpful if you need assistance managing a chronic health condition.
CHT Staff Has Expertise in Many Areas
The following snapshot gives you an idea of who we are, and what we do:
- Behavioral Health Specialist – Provides behavioral health risk assessment and brief interventions to overcome barriers so patients can make healthier lifestyle changes. Helps with finding long-term therapy, if needed.
- Care Coordinator, RN – Helps clients access services, manage medications, and makes sure patients are getting the care that they need.
- Certified Diabetes Educator, RN & RD – Provides education and support for patients managing diabetes.
- Health Coach – Helps patients design and implement an individualized nutrition and exercise plan to help with weight loss and/or chronic disease management.
- Registered Dietitian/Nutritionist – Provides nutrition and lifestyle counseling for diabetes, hypertension and high cholesterol, kidney disease, food allergies, food medication interactions (i.e., Coumadin), intestinal disorders such as irritable bowel, Crohn’s disease, colostomies, patients planning to undergo bariatric surgery and those with other complicating medical factors (e.g. feeding tubes, cancer nutrition therapy).
- Pediatric Care Coordinator – Provides case coordination and refers children and their families to needed community services.
- Scheduler/Assistant – Assists with scheduling initial patient appointments, any follow-up visits, or appointment changes.
- Self-Management Coordinator – Helps patients quit smoking and manage chronic health conditions through topic-specific workshops.
- Clinical Social Worker – Helps connect patients with services they need, including disability benefits, housing, elder care, support for end of life issues, Medicare enrollment, legal referrals, transportation assistance, and stress reduction groups.
We Also Help With Other Issues:
- financial challenges
- emotional issues
- educational needs
- substance use disorder
- transportation and/or physical assistance.
CHT Services Include:
- Chronic Disease Management
- Connection to Community and Financial Resources
- Diabetes Education
- Health Education
- Medication Management
- Mental Health/Substance Abuse Assessments and Brief, Client Centered Treatment
- Nutrition Counseling & Therapy
- Exercise Education & Counseling
- Weight Management
- Much more!
CHT’s Collaborative Approach
We’ll work closely with you (both one-on-one here in our offices and/or in your home if you wish) and with your primary healthcare team to provide services that meet your individual goals. With a focus on both treatment and prevention, CHT staff helps patients set goals and receive the education and tools they need to:
- Eat healthier
- Become more physically active
- Quit smoking
- Understand their treatment plan
- Manage their medications
- Manage their health condition(s)
- Connect with local resources such as transportation services and community walking paths
- Talk to someone about challenges that may be getting in the way of leading a healthier life
- Transition from hospital-level care back to a primary care physician
- Prevent small problems from becoming big ones.