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

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.

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.