Care Managers connect patients, providers and community partners at Community Health

Susan Maravalli is a care manager. Her gentle laughter tempers the determination she shows as she describes the situations and the people she encounters every day at Community Health Castleton. “It’s a hard health care system to navigate,” Maravalli said. “Patients have so many health concerns and barriers they don’t know how to handle. They need care management.”

Maravalli is a nurse, a wellness coach, a medical liaison, a researcher of community services, a trusted listener, a provider of support, a safe harbor and a wealth of knowledge when it comes to navigating the health care system.

Care management is playing an increasingly important role in helping everyday individuals manage their health care. Community Health recognized the value of care management about a decade ago, and has built a program that currently supports about 3600 patients of all ages and socioeconomic backgrounds.

The young overweight homeless man on the verge of heart failure; the elderly dialysis patient who couldn’t find transportation to treatments; a walk-in patient with short-term memory loss; the diabetic with multiple medications and complex health issues; the child with autism and juvenile diabetes. These are all challenging medical and environmental situations that Maravalli embraces with the enthusiasm of a tenacious medical detective and the deep understanding of how difficult it is to navigate the intricacies of the health care system. A care manager works directly with patients and matches patient needs with appropriate services, working alongside providers, office staff and government services and liaises with community organizations, hospitals and medical specialists.

Community Health’s care management program has been recognized nationally for the system designed and implemented by Clinical Director Claudia Courcelle, RN, BSN, MSA, and a team of health care providers focused on quality care. In 2019, Courcelle’s Community Wide Care Management program was selected by the American Academy of Ambulatory Care Nursing to be included in the organization’s online library of care management programs from around the country.

“Originally the program was set up for primary care patients who had complex medical diagnoses,” Courcelle said. “The concept has now been expanded to include behavioral health and the medication assisted treatment (MAT) program with care managers specifically trained to deal with substance abuse recovery,” she said.

Patients who would benefit most from a care manager are challenged by medical, social and economic “social determinants.” Social determinants are defined as conditions in the environment where people live, learn, work, play, worship and age that effect a wide range of health and quality of life outcomes. Conditions might include somebody who has medically complex or comorbid diagnosis, or someone who had issues with transportation or lack of food or housing. These social determinants would make a person a candidate for care management.

“We live in a society where patients are obese and have hypertension, lack exercise, don’t have healthy diets,” Courcelle said. “Wellness is a huge focus for us.”

“A lot of what we do is coordination of care,” Maravalli said. “I’ve had to get economic services involved, homeless prevention. We do a lot with transitions – transitions into the hospital, out of the hospital, into the hospital to tertiary care centers; from tertiary centers back to subacute rehab, to our local hospital to home with nursing services. Community partners play a huge role.”

The U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality defines care management as a “team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. It also encompasses those care coordination activities needed to help manage chronic illness.“ Unlike case management which is disease-centric, care management focuses on intervention and reducing health risks of a population of individuals.

Community Health’s care management program has been growing since 2011. “We initially had a care manager in the Rutland and Castleton practices,” Courcelle said. The care management staff now includes 20 managers and coordinators who work at each of Community Health’s Rutland, Castleton, Shorewell, Brandon and Mettowee practices, as well as Community Health Pediatrics. Care coordinators are embedded in the three subacute centers supported by Community Health’s nursing home service line at Mountain View Center, Rutland Healthcare and Rehabilitation Center, and The Pines for Nursing and Rehabilitation.

“Care managers support our patients who have comorbid diagnoses such as hypertension, heart disease, liver disease; anything that requires attention and support,” Courcelle said. “Or it could be somebody who is just going through a challenging time and once they get through that hurdle may not need to be actively care managed.”

Each care manager works with anywhere from 50-100 patients who need ongoing support daily, weekly or monthly, depending on the patient needs. “We care manage everybody,” Courcelle said. “However, we have two programs that are more specific.”

• The Chronic Care Management (CCM) program is designed for qualified Medicare and Medicaid patients who opt to be in the program.
• The Shared Care Plan is through Vermont’s OneCare accountable care organization (ACO), a collaborative approach to sharing health care information with community partners.

“During the first three months of Covid when everyone was socially isolated, the care managers were saviors to our patients,” Courcelle said. “We had so many patients who were stressed, worried, had anxiety or seemed uncomfortable going in to see their provider. Some of them were getting telemedicine, but a lot of them used the care managers as a resource to help them during tough times.”

So, what are the skills needed to be a care manager? “Nurses who become care managers need to be high functioning expert nurses. They need to be very knowledgeable and seasoned in their specialty with a great deal of experience and have a good skill set because they are interacting with patients, providers and community stakeholders,” Courcelle said.

Is care management a growing service? “Many independent companies provide care management services you can consult with. We have found that internal care management within our health care organization is best because they know their patients well, they are part of the team and they have a physical presence,” Courcelle said.

Care managers have become the go-to experts at Community Health. If there is a complicated situation, providers consult the care managers because they possess a wealth of knowledge about the community resources. “We are the glue that holds it together for folks,” Maravalli said. “It’s about teamwork. Everyone in the community plays a part to ensure that patients have what they need.”

All Community Health practices are open for in-person and Telehealth appointments with medical, dental and behavioral health providers. Check the Community Health website and Facebook page for more information about care management, primary care services and detailed contact information.

Claudia Courcelle, RN, BSN, MSA, joined Community Health in 2008. Educated at New York City’s Hunter College Bellevue School of Nursing, Courcelle moved to Vermont over 30 years ago.

She has worked in medical-surgical nursing, emergency department, endoscopy as a certified gastroenterology nurse and, before joining Community Health, was a staff development specialist at Rutland Regional Medical Center(RRMC). Overseeing the Community Health’s care management program, Courcelle has helped develop a robust program with care managers in all Community Health practices, working closely with RRMC and other community partners.

Susan Maravalli, RN, joined Community Health in 2002. A 1983 graduate of University of Rhode Island School of Nursing, she initially worked in a hospital setting but family medicine and pediatrics became her passion. She joined Community Health Pediatric and transitioned to the Care Management program about five years ago. She currently supports about 50 patients at Community Health Castleton.

The U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality defines care management as a “team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. It also encompasses those care coordination activities needed to help manage chronic illness.“ Unlike case management which is disease-centric, care management focuses on intervention and reducing health risks of a population of individuals.

Community Health’s care management program has been growing since 2011. “We initially had a care manager in the Rutland and Castleton practices,” Courcelle said. The care management staff now includes 20 managers and coordinators who work at each of Community Health’s Rutland, Castleton, Shorewell, Brandon and Mettowee practices, as well as Community Health Pediatrics. Care coordinators are embedded in the three subacute centers supported by Community Health’s nursing home service line at Mountain View Center, Rutland Healthcare and Rehabilitation Center, and The Pines for Nursing and Rehabilitation.

“Care managers support our patients who have comorbid diagnoses such as hypertension, heart disease, liver disease; anything that requires attention and support,” Courcelle said. “Or it could be somebody who is just going through a challenging time and once they get through that hurdle may not need to be actively care managed.”

Each care manager works with anywhere from 50-100 patients who need ongoing support daily, weekly or monthly, depending on the patient needs. “We care manage everybody,” Courcelle said. “However, we have two programs that are more specific.”

• The Chronic Care Management (CCM) program is designed for qualified Medicare and Medicaid patients who opt to be in the program.
• The Shared Care Plan is through Vermont’s OneCare accountable care organization (ACO), a collaborative approach to sharing health care information with community partners.

“During the first three months of Covid when everyone was socially isolated, the care managers were saviors to our patients,” Courcelle said. “We had so many patients who were stressed, worried, had anxiety or seemed uncomfortable going in to see their provider. Some of them were getting telemedicine, but a lot of them used the care managers as a resource to help them during tough times.”

So, what are the skills needed to be a care manager? “Nurses who become care managers need to be high functioning expert nurses. They need to be very knowledgeable and seasoned in their specialty with a great deal of experience and have a good skill set because they are interacting with patients, providers and community stakeholders,” Courcelle said.

Is care management a growing service? “Many independent companies provide care management services you can consult with. We have found that internal care management within our health care organization is best because they know their patients well, they are part of the team and they have a physical presence,” Courcelle said.

Care managers have become the go-to experts at Community Health. If there is a complicated situation, providers consult the care managers because they possess a wealth of knowledge about the community resources. “We are the glue that holds it together for folks,” Maravalli said. “It’s about teamwork. Everyone in the community plays a part to ensure that patients have what they need.”

All Community Health practices are open for in-person and Telehealth appointments with medical, dental and behavioral health providers. Check the Community Health website and Facebook page for more information about care management, primary care services and detailed contact information.

Claudia Courcelle, RN, BSN, MSA, joined Community Health in 2008. Educated at New York City’s Hunter College Bellevue School of Nursing, Courcelle moved to Vermont over 30 years ago.

She has worked in medical-surgical nursing, emergency department, endoscopy as a certified gastroenterology nurse and, before joining Community Health, was a staff development specialist at Rutland Regional Medical Center(RRMC). Overseeing the Community Health’s care management program, Courcelle has helped develop a robust program with care managers in all Community Health practices, working closely with RRMC and other community partners.

Susan Maravalli, RN, joined Community Health in 2002. A 1983 graduate of University of Rhode Island School of Nursing, she initially worked in a hospital setting but family medicine and pediatrics became her passion. She joined Community Health Pediatric and transitioned to the Care Management program about five years ago. She currently supports about 50 patients at Community Health Castleton.