Care Management Ramps Up at Community Health

Wendy Oliver, LPN, CCHW, Craig Chambers and Laurel Burns, RN (left to right) enjoy the sunshine outside.

It had been close to three years since Craig Chambers had been outside the confines of his Castleton apartment. Watching him emerge from his home after the years of isolation was not just heartwarming. It was a relief. The thought of being trapped inside for three years was frightening and beyond comprehension. And yet it happened. As his wheelchair rolled through the front door and down the newly constructed metal ramp there were moments of tears and bursts of cheers.

“Laurel and Wendy helped me with all the wheelchair phone calls and ramp widening so I can get out in an easy manor,” Chambers said. “I am really grateful to Wendy for helping me with the wheelchair.  Now I can get out on a regular basis.”

“We worked closely with Craig,” said Laurel Burns, RN and Community Health Care Manager. “We developed a team with community partners, guided by H. Peter Diercksen, MD,  Craig’s Community Health primary care provider. We communicated how to use each other to maximize the support he had at home, in the community and remotely from the Castleton practice.”

“It’s difficult to focus on your medical care when you don’t have a place to live or can no longer afford your medications.”

– Claudia Courcelle, Community Health Director of Care Management

Because of Chambers’ limitations and health issues, it was complicated. But persistence and a focused care management team produced results. Chambers’ landlord agreed to widen the doorways in the apartment to accommodate a wheelchair and local social worker organizations like Vermont Center for Independent Living of Rutland provided support. The Southwestern Vermont Council on Aging provided some funding for construction of the ramp and Community Health’s Clinical Community Health Worker Wendy Oliver pursued manufacturers and suppliers for a motorized wheelchair. “Wendy really was tenacious,” Burns said.

“So many of our patients struggle with mental illness especially through the pandemic,” Burns said. “They disengage.” So, to keep the 57-year-old engaged, the care management team developed a plan to connect with his social worker along with his medical and behavioral health providers at Community Health where his primary care is a priority.

“We have to keep thinking of ways to put safety nets around our patients.”

– Laurel Burns, RN Community Health Care Manager

Chambers’ story is one of many challenges that Community Health’s care managers encounter every day. Chambers agreed to share the results of the team effort that led to a new perspective on his life for him and the goals he’s set for himself like attending his son’s wedding and using some of his woodworker skills again.

Oliver joined Burns a year ago as part of Community Health’s care management team, a support service within Community Health’s primary care network. As the first member of the care management team 11 years ago, Burns has seen care management evolve, at first developing outreach to local hospitals and nursing homes for patients transitioning in and out of their facilities. Now 33 care managers staged at all Community Health locations, including primary care, pediatrics, behavioral health and skilled nursing facilities, link the continuum of care to wellness, health management and addressing social barriers like transportation, safe housing, education, language and literacy skills which complicate those with medical complexity even more.

“Both 2020 and especially 2021 have been challenging years for care managers,” said Claudia Courcelle, Community Health Director of Care Management. “Patients and their families have the added experience of COVID which has greatly increased the support from our team.  We have also identified a much higher level of behavioral health concerns, stress and anxiety which only contribute to the needs of our very complex medical patients.”

It’s difficult to focus on your medical care when you don’t have a place to live or can no longer afford your medications, Courcelle added. Care managers fill in those gaps of care, providing resources, services and care coordination working closely in the community, with the Community Health practice site teams and providers.

“Care management will grow and expand,” Burns said. “We have to keep thinking of ways to put safety nets around our patients. It can look overwhelming. You have to go small and look at the successes.”

With Baby Boomers coming of age, there will need to be innovative approaches to care such as technology in home care, communal living, telemedicine, remote work and home visits by providers. And that is where care management comes in.

“Our team will continue to serve as a primary resource for our very complicated patient population which continues to grow,” Courcelle said. “We will work collaboratively with our community stakeholders and our accountable care organization (ACO), OneCare Vermont, to provide the highest level of care to our patients and support the needs of their families to serve in their health promotion.”

“We have all learned to pivot during the pandemic,” Burns said. “I’ve had to be adaptable, open minded, forward thinking, understand community partners, maximize what you have and be creative. This is why primary care is so key.”

Follow this series of stories over the next three months, every Friday, as we discuss primary care, value-based care and Community Health’s role in providing high quality health care services that include support groups and educational programs. This year, Community Health is expanding the diabetes education program. With 13% of the Rutland County population now diagnosed with some form of diabetes, Community Health will be focusing on treatment options using prevention and wellness to guide patients.

Laurel Burns, RN, earned her nursing degree at SUNI Adirondack. Her nursing career has focused on primary care. She joined Community Health in 2011.

Wendy Oliver, LPN, CCHW, joined Community Health’s care management team in 2021 as a Clinical Community Health Worker, having spent her 32-year career mostly in long-term care. She most recently worked at The Pines at Rutland Center for Nursing and Rehabilitation.

Claudia Courcelle, RN, BSN, MSA, CCM is Community Health’s Director of Care Management.

Community Health is Vermont’s largest Federally Qualified Health Center (FQHC), a network of primary care, pediatric, behavioral health, dental and pharmacy services with offices in Rutland, Brandon, Castleton, West Pawlet and Shoreham. Community Dental offices are located in Rutland and Shoreham; Community Kids Dental is in Rutland; Community Health Pediatrics is in Rutland and Behavioral Health services are available at all of our locations. Community Health Express Care Centers, open 7 days a week, are located at the Rutland and Castleton Community Health Centers. For more information about Community Health, check our website https://www.chcrr.org/.