initiatives also have skilled leaders who can coordinate the interests of stakeholders, including hospital administrators and state and local health, housing, and mental health departments, at the system level (Craig et al., 2011). Box 7-3 describes an example of a community initiative aimed at improving care delivery and health outcomes through better care coordination.

BOX 7-3
Vermont Blueprint for Health

Communities of integrated health services, spanning organizations and clinicians, are an example of the evolving definition of communities—in this case focused on care coordination. Community-based teams support patient-centered services, helping to better coordinate and more seamlessly transition care across a spectrum of services in a community. One example is the Vermont Blueprint for Health, a statewide public-private initiative that seeks to transform care delivery; improve health outcomes; and expand access to seamless, well-coordinated care. As a key component of Vermont’s Multi-Player Advanced Primary Care Practice Demonstration, a pilot program sponsored by the Centers for Medicare & Medicaid Services, the Vermont Blueprint for Health operates through a network of integrated medical homes, each supported by an integrated information technology infrastructure and community health teams. These teams are typically composed of nurse coordinators, social workers, and behavioral health counselors working to improve health outcomes while containing costs through the provision of coordinated care.

By extending health care delivery to services not typically provided in the primary care setting, these community health teams are able to provide individual care coordination, health and wellness coaching, and behavioral health counseling as an integrated and coordinated set of services. Nurse coordinators primarily track patient activities within physician practices by following up on overdue appointments or tests, ensuring proper refilling of and adherence to prescriptions, working with patients to achieve their personal health management goals, and overseeing short-term care for high-need patients. Behavioral health coordinators also work within physician practices, monitoring patients for any untreated mental health conditions and ensuring speedy follow-up for those who require it. Outside of the primary care practices, community health workers assist patients in applying for insurance, adhering to treatment plans, managing stress, and progressing toward their personal wellness goals. Public health specialists facilitate closer coordination between the community health team and public health initiatives, while dietitians provide nutrition education and work with diabetic patients to manage their conditions. This team approach to better self-management has yielded many successes for the Blueprint initiative, including a 31 percent decrease in emergency department use and a 36 percent decrease in associated costs per person per month.

SOURCE: Bielaszka-DuVernay, 2011.

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