The Vermont Blueprint for Health: Redefining Primary Care

The following is an excerpt from our 2011 Annual Report. Our 2012 Annual Report will be out soon.

Vermont Blueprint

Blueprint Care Coordinator Keith Marino meets in Gifford primary care with patient Cheryl Abbey of Randolph.

The Vermont Blueprint for Health is a state-led initiative aimed at improving care coordination, especially for the chronically ill. The goals of the initiative are to improve health, enhance the patient experience and reduce, or at least control, health care costs.

This is accomplished through what the Blueprint is calling “advanced primary care” that seamlessly coordinates a broad range of health and human services for patients and their families.

In 2011, the Vermont Blueprint for Health came to life at Gifford. Each of the medical  center’s primary care practices was recognized as a Patient-Centered Medical Home and a huge care coordination effort got under way to meet patients’ diverse needs.

The care coordination effort, which is supported in part by grant dollars, is twofold. First, Gifford formed its own small care coordination team made up of three core employees; Blueprint Care Coordinator Keith Marino, Gifford Diabetes Educator Jennifer Stratton and
Health Connections Caseworker Michele Packard. Second, a larger Community Health Team consisting of a diverse group of state and regional community housing, aging and disability agencies as well as eye care professionals, a pharmacy, insurers and more, was formed.

Vermont Blueprint

Blueprint core team members – Health Connections caseworker Michele Packard and diabetes educator Jennifer Stratton – meet weekly with Blueprint Care Coordinator Keith Marino at the Bethel Health Center to discuss individual patients and how to better serve them.

The Community Health Team meets quarterly while a care coordination team meets weekly. More importantly, referrals are bouncing back and forth between the agencies and teams ensuring patients are getting the services they need to maintain and improve their health. Keith coordinates this work, meeting directly with patients, spending time in each
of Gifford’s Patient-Centered Medical Homes, conferring with health care providers and helping patients access needed services.

Patients and community members are referred to Keith for a huge variety of reasons. They may need help managing chronic conditions, be struggling socio-economically, need mental health assistance, be disabled or elderly, have housing or transportation needs or just need help navigating the health system.

The Blueprint provides that help directly or refers them to an appropriate community agency. The help comes in the form of one-on-one meetings with Keith and outreach on his part to get the patient connected with needed resources.

“My role is to make sure patients are getting access to proper services, which enables them to self-manage their chronic condition,” Keith says.

Medicine Division Vice President Teresa Voci gives the example of a chronically ill patient who, because of financial pressures, has to choose between food and medication. Without medication, their health suffers. With the Blueprint services, their health care provider has a central resource to offer the patient for those issues that fall outside the health care setting but are barriers to care, like help with finding resources to buy food and medications.

Kim Flood of Barre is a real life example.

All three of Kim’s sons were diagnosed with asthma. The younger two, ages 4 and 1, were especially sick, including being hospitalized. Kim thought she knew the problem – mold in her Barre apartment.

Pediatric hospitalist Dr. Lou DiNicola referred Kim to the Blueprint. “Keith helped us find someone to do mold testing, help us with legal aid,” Kim says, “and he got city officials to come to the apartment. I had tried for months to get the housing inspector and building inspector to our house. I just got the runaround from everyone.”

With the mold verified and the help of legal aid, Kim settled with the landlord and in October moved into a home she bought in Barre Town on nine acres.

The kids haven’t been sick since.

Kim is one of 230 referrals Gifford’s Blueprint team has received since Keith was hired and the program got under way in February, notes Blueprint Project Coordinator LaRae Francis. Most of the referrals are from primary care providers, like Dr. Terry Cantlin of the Bethel Health Center.

“He’s been invaluable,” says Dr. Cantlin of Keith, who does the work primary care physicians simply do not have time to do in their busy practices.

Now if a patient is not taking their medication due to financial pressures, is missing needed appointments because of transportation issues or struggling with social issues – all scenarios Dr. Cantlin sees – he now has a one-stop resource for the patient.

It also prevents patients unaware of available community resources from “falling through the cracks,” says Mary Ellen Otis, executive director of the Orange County Parent Child Center in Chelsea.

That center, which provides a vast array of family services from new baby visits to parenting education, is part of the Community Health Team and refers clients to Gifford as well as gets referrals from the hospital. Under the new coordinated effort, Mary Ellen says, referrals are now far more efficient.

Maryette Withington can attest to that.

The Barnard resident has a relative with Alzheimer’s disease. Dr. Cantlin referred Maryette to Keith for help learning more about the disease. He met with her at the Bethel Health Center and connected her with the Randolph Area Senior Center and the Vermont Chapter of the Alzheimer’s Association. Within 24 hours Maryette had information in her hands about the disease that she says has changed everything in her life.

“You’re totally responsible for that person. I just needed to know what to expect.”

She will have an ongoing relationship with the association and also continues to receive help from Keith, Dr. Cantlin and her Gifford health care team. It’s help she appreciates. “I have the best health care team in the world,” she says.

Need help yourself? Call the Blueprint Care Coordinator at (802) 728-2499.

Free Heart Series Begins Feb. 20

free heart series

Gifford’s Pharmacy Manager Jane McConnell speaks to a chronic illness group. A dynamic and thoughtful speaker, McConnell will be among the speakers in our new monthly heart health series, “Matters of the Heart”.

Gifford Medical Center launches a new monthly educational series next week for anyone concerned about their heart health.

Called “Matters of the Heart,” the series starts on Feb. 20 and continues on the third Wednesday of each month from 1-2 p.m.

The free talks feature experts from Gifford talking about heart healthy topics, such as diet, exercise and managing stress.

Behavioral health specialist Samantha Medved, a licensed social worker, kicks of the series with “Stress 101.” On March 20, registered dietitian Stacy Pelletier talks about “Heart Healthy Oils.” On April 17, pharmacist Jane McConnell discusses “Cardiac Medications,” and chef Steve Morgan leads a talk on “Reducing Salt” on May 15.

“This series will certainly benefit heart patients, including those recovering from a heart attack or suffering from heart disease or high blood pressure,” says Ed Striebe, director of hospitality and food services at Gifford. “Good heart health is vitally important for everyone, however, so this series is truly open to all.”

The educational series continues throughout the year. A complete schedule of talks is available online at www.giffordmed.org. All talks are in the Conference Center, except those led by Gifford’s chefs. Those discussions are held in the cafeteria.

No registration is required. For more information, call Striebe at (802) 728-2191.

“Like” Gifford on Facebook to receive notifications of upcoming free educational events like these.

Eighth Annual Diabetes Education Expo March 15

Free event focuses on eye care, shopping on a budget and more

Diabetes Education Expo

Certified diabetes educator and registered dietitian Jennifer Stratton works with a patient in Gifford’s Diabetes Clinic at the Kingwood Health Center in Randolph. (File photo)

RANDOLPH – A diabetes diagnosis can be overwhelming. But Gifford Medical Center is striving to make living with diabetes easier this March when it holds its eighth annual free Diabetes Education Expo.

Sharing everything from eating healthy and cooking on a budget to simple exercises one can do at home, the March 15 expo aims to provide a “Road Map to Managing Your Diabetes.”

Also covered will be eye care in a talk by Dr. Dean Barcelow of Bethel’s Eye Care for You and a discussion by behavioral health specialist Sam Medved on the steps and challenges of making lifestyle changes. A cooking demonstration will be provided and vendor booths will include the latest in diabetes products as well as help from Gifford’s Blueprint Community Health Team in overcoming obstacles to successful self-management.

According to 2011 data from the American Diabetes Association, 25.8 million children and adults, or nearly 8.3 percent of the population, have diabetes nationally. In Vermont, the disease affects more than 55,000 people, according to the Department of Health.

Diabetes is marked by high levels of blood glucose resulting from the body not producing or improperly using insulin – the hormone needed to convert sugar, starches and other food into energy for daily living.

To remain healthy, diabetics must have regular checks of eyes, feet, teeth and more and they must take an active role in managing their diabetes through diet, exercise, monitoring their blood glucose and taking medications, if required.

“A diabetes diagnosis and daily living can be overwhelming because it can mean lots of lifestyle or behavior changes,” says Gifford certified diabetes educator and registered dietitian Jennifer Stratton. “I often recommend gradual changes that are doable for the patient and don’t break the bank.

“This year’s Diabetes Education Expo is an extension on that. We’ll talk about how to buy healthy foods on a budget, we’ll demonstrate cooking healthy foods to make them delicious and enjoyable, and we’ll show you simple exercises that you can do at home, without a gym membership or high-tech equipment.”

In fact, there’s a lot a diabetic can do to manage their disease – even their eye health.

Diabetes can damage small blood vessels in the eye’s retina, the back part of the eye. Diabetes also increases one’s risk of having glaucoma, cataracts and other eye problems.

Dr. Barcelow, an optometrist, will share what he’s looking for in the eye when it comes to signs of disease and talk about what patients can do prevent eye problems.

“I like to tell my patients that diabetes is kind of a lifestyle,” he says, listing taking medications as prescribed, diet and exercise as keys to a successful diabetic lifestyle.

To hear Dr. Barcelow, Stratton and the event’s other speakers map out diabetes self-management, sign-up for the expo by March 8. Seating is limited. Call Zach Bean at (802) 728-7100, ext. 6 to register.

The expo takes place from 9 a.m. to 2 p.m. Use the southern entrance of the hospital (before the Thrift Shop) on Route 12 in Randolph. Get directions and learn more online at www.giffordmed.org.

Diabetes Education Expo Agenda
9 a.m. – Registration, vendor/information booths open
10-10:45 a.m. – Eye Care for Diabetes, Dr. Dean Barcelow, Eye Care for You
10:45-11:15 a.m. – Exercise, Jane McConnell, Gifford pharmacist and exercise enthusiast
11:15 a.m. to noon – What’s Next, Making Changes, Samantha Medved, Gifford behavioral health specialist
Noon-1 p.m. – Lunch
1-1:30 p.m. – Eating Right When Money’s Tight, Jennifer Stratton and Stacy Pelletier, Gifford registered dietitians
1:30-2 p.m. – Cooking demonstration, Chef Steve Morgan, Gifford
2 p.m. – Raffle drawings