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Care Management

What is Care Management?

Our Care Management team works alongside our primary care providers helping you manage your condition and medications while connecting you to the resources and support you need.

Community Health has embedded Care Managers in all our practices to serve primary care, behavioral health, and pediatrics for patients of all ages and conditions. Care Managers can assist with:

  • Chronic health conditions
  • Medication management
  • Diabetes self-care
  • Transportation, housing, and food insecurity
  • Eldercare
  • Behavioral health issues for all age groups
  • Substance abuse
  • Pediatric support and newborn care

Care Managers are experienced medical professionals and members of the community who know how to access combined powers of health and wellness, educational resources, and community services.

How does Care Management work?

Primary care providers refer patients to Care Managers who create customized care plans to address specific needs. The process includes:

  • One-on-one communication with a Care Manager
  • Follow-up phone calls
  • Coordination with community resources and social services

Care Management and coordination reduces health risks

Care Management focuses on reducing health risks by organizing appropriate interventions such as:

  • Organizing appointments to avoid missing preventative, primary care, or specialist visits
  • Understanding medications and treatments
  • Self-care practices
  • Information about ways to have fewer emergency room visits

Care Managers are advocates for your unique needs

Care Managers work as a team with primary care providers to understand and overcome struggles a person may encounter as they regain, maintain, and improve their health and the health of their family.

Care Managers help coordinate:

  • New medications
  • Appointments with hospitals and specialists
  • Being discharged from or admitted to the hospital
  • Receiving a new diagnosis

As advocates, Care Managers support your unique needs and help you develop your own wellness plan as your healthcare needs may change.

Who qualifies for Care Management?

All patients qualify for Care Management. It is unique to each patient and what their needs are. It can be short-term due to an unexpected medical diagnosis in, which the patient needs limited support, or long-term for chronic illness.

Referrals are the key source for determining which patients require Care Management services. Referrals are reviewed to determine patient needs and are placed for patients needing extra support with the following:

  • Chronic health conditions
  • Medication management
  • Diabetes self-care
  • Transportation, housing, food insecurity
  • Eldercare
  • Behavioral Health
  • Substance use disorders
  • Pediatric support, newborn care, or caregiver support

Patients and caregivers may also request Care Management services. Care Managers can be consulted for assistance with patients who do not require the Care Management program but for whom the care team requires additional support to meet the patient’s needs.

How do I get a Care Manager?

If you feel that a Care Manager could support you, contact your provider.

Care Managers will use a tool that is built into our electronic health record (EHR) to identify the most complex patients who require care management services. Patients will be grouped into four risk levels (low, medium, high, very high) using clinical data from our EHR.

This allows Care Managers to better focus on patients with the highest risk to improve patient outcomes.

The tool assesses the following information:

  • Demographics (age, address, race, sex, gender identity, sexual orientation, etc.)
  • Clinical diagnoses (behavioral health, special needs, physical limitations)
  • Quantity of medications prescribed
  • Frequency of medical visits to the Emergency Department, Express Care, primary care, nursing homes/rehab
  • Non-medical factors that influence health outcome, such as income, job insecurity, food insecurity, housing


Care Management Locations

Mountain View Center

9 Haywood Avenue
Rutland, VT 05701

The Pines at Rutland

99 Allen Street
Rutland, VT 05701

Community Health Mettowee

278 VT Route 149
West Pawlet, VT 05775

Community Health Brandon

420 Grove Street
Brandon, VT 05733

Community Health Castleton

275 Route 30 North
Bomoseen, VT 05732

Community Health Rutland

215 Stratton Road
Rutland, VT 05701

Pediatrics clinic exterior

Community Health Pediatrics

1 General Wing Road
Rutland, VT 05701

Community Health Shorewell

2987 VT Route 22A
Shoreham, VT 05770