Working with the community to determine the design and functions of the CHT Facilitating the CHT, the extended CHT, and other community-based forums Working closely with Vermont Information Technology Leaders (VITL) to organize efforts to connect practices to the Vermont Health Information Exchange (VHIE) and the central clinical registry (DocSite) Developing relationships with buprenorphine providers to support service improvements for treating opioid addiction Staffing support and guidance for the Unified Community Collaboratives. [1] oversees the integration and monitoring of the CHT Care Integration Coordinator: components; builds and sustains community partnerships with organizations via the Extended Community Health Team. The CIC provides direct management and oversight to the Community Connections Team. The CIC organizes and facilitates formal opportunities for collaboration and encourages informal communication among team members. For example: the CIC holds frequent meetings with the APCPs and the community Connections Team, and larger meetings with the Extended Community Health Team. [1] Organizational Structure—Community Connections Team The Community Connections Teams are comparable to Rhode Island’s community health teams in that the CCT includes a field based care management team that addresses patient psychosocial needs. Differences include addressing health education and chronic disease management. The CCT works with the chronic care coordinator to ensure coordinated care. Core CCT characteristics and components include: Staffing: Comprised of two community health workers (CHWs) and one Chronic Care community health worker (CC CHW). 1 describes their roles and responsibilities in detail. The CHT also includes a behavioral health specialist. CHWs help patients develop an action plan to manage chronic conditions and link clients to community-based, local and state agencies that can provide financial and other tangible resources to meet client’s needs. Using an asset-based model of care, CHWs help clients identify what resources are available to them based on their needs, and the community-based organizations and services available. Develop and implement client-centered action and then follow up with clients on a regular basis to help them implement the action plans. Use motivational interviewing techniques to help clients explore and realize their capacity to make a behavior change that is in their best interests CC CHWs serve as health coaches. They conduct health assessments, play an active role in reinforcing provider-initiated treatment plans, provide hands-on assistance in support of chronic disease management, self-management and teach stress management techniques. Serve same function as CCW but also act primarily as health coaches to help clients improve chronic disease management skills.
Working with the community to determine the design and functions of the CHT Facilitating the CHT, the extended CHT, and other community-based forums Working closely with Vermont Information Technology Leaders (VITL) to organize efforts to connect practices to the Vermont Health Information Exchange (VHIE) and the central clinical registry (DocSite) Developing relationships with buprenorphine providers to support service improvements for treating opioid addiction Staffing support and guidance for the Unified Community Collaboratives. [1] Care Integration Coordinator: oversees the integration and monitoring of the CHT components; builds and sustains community partnerships with organizations via the Extended Community Health Team. The CIC provides direct management and oversight to the Community Connections Team. The CIC organizes and facilitates formal opportunities for collaboration and encourages informal communication among team members. For example: the CIC holds frequent meetings with the APCPs and the community Connections Team, and larger meetings with the Extended Community Health Team. [1] Organizational Structure—Community Connections Team The Community Connections Teams are comparable to Rhode Island’s community health teams in that the CCT includes a field based care management team that addresses patient psychosocial needs. Differences include addressing health education and chronic disease management. The CCT works with the chronic care coordinator to ensure coordinated care. Core CCT characteristics and components include: Staffing: Comprised of two community health workers (CHWs) and one Chronic Care community health worker (CC CHW). 1 describes their roles and responsibilities in detail. The CHT also includes a behavioral health specialist. CHWs help patients develop an action plan to manage chronic conditions and link clients to community-based, local and state agencies that can provide financial and other tangible resources to meet client’s needs. Using an asset-based model of care, CHWs help clients identify what resources are available to them based on their needs, and the community-based organizations and services available. Develop and implement client-centered action and then follow up with clients on a regular basis to help them implement the action plans. Use motivational interviewing techniques to help clients explore and realize their capacity to make a behavior change that is in their best interests CC CHWs serve as health coaches. They conduct health assessments, play an active role in reinforcing provider-initiated treatment plans, provide hands-on assistance in support of chronic disease management, self-management and teach stress management techniques. Serve same function as CCW but also act primarily as health coaches to help clients improve chronic disease management skills.
CHT%20Program%20Literature%20Review%20Part%20II%20Vermont%20program.docx