Patients in primary care practices need additional support to manage chronic conditions and overcome obstacles to better self-care.
Community health teams—comprising nurse coordinators, behavioral health counselors, and social workers—help primary care practices assess patients' needs, coordinate community-based support services, and provide multidisciplinary care, through a program organized by the Vermont Blueprint for Health, a public–private partnership. The cost of teams, which offer individual care coordination and health and wellness coaching among other services, is shared by three major commercial insurers and state's Medicaid program.
The statewide program led to significant year-over-year decreases in hospital admissions (21%) and emergency department visits (31%). Objective assessments suggest early improvements in clinical quality and use, such as better control of hypertension.