Vermont § 705 - Community health teams

§ 705. Community health teams

• (a) Consistent with federal law to ensure federal financial participation, the community
  health team shall consist of health care professionals from multiple disciplines,
  including obstetrics and gynecology, pharmacy, nutrition and diet, social work, behavioral
  and mental health, chiropractic, other complementary and alternative medical practice
  licensed by the State, home health care, public health, and long-term care. (b) The Director shall assist communities to identify the service areas in which the teams
  work, which may include a hospital service area or other geographic area. (c) Health care professionals participating in a community health team shall: (1) Collaborate with other health care professionals and with existing State agencies
  and community-based organizations in order to coordinate disease prevention, manage
  chronic disease, coordinate social services if appropriate, and provide an appropriate
  transition of patients between health care professionals or providers. Priority may
  be given to patients willing to participate in prevention activities or patients with
  chronic diseases or conditions identified by the Director of the Blueprint. (2) Support a health care professional or practice that operates as a medical home, including
  by: (A) assisting in the development and implementation of a comprehensive care plan for a
  patient that integrates clinical services with prevention and health promotion services
  available in the community and with relevant services provided by the Agency of Human
  Services. Priority may be given to patients willing to participate in prevention activities
  or patients with chronic diseases or conditions identified by the Director of the
  Blueprint; (B) providing a method for health care professionals, patients, caregivers, and authorized
  representatives to assist in the design and oversight of the comprehensive care plan
  for the patient; (C) coordinating access to high-quality, cost-effective, culturally appropriate, and patient-
  and family-centered health care and social services, including preventive services,
  activities that promote health, appropriate specialty care, inpatient services, medication
  management services provided by a pharmacist, and appropriate complementary and alternative
  (CAM) services; (D) providing support for treatment planning, monitoring the patient’s health outcomes
  and resource use, sharing information, assisting patients in making treatment decisions,
  avoiding duplication of services, and engaging in other approaches intended to improve
  the quality and value of health services; (E) assisting in the collection and reporting of data in order to evaluate the Blueprint
  model on patient outcomes, including collection of data on patient experience of care,
  and identification of areas for improvement; and (F) providing a coordinated system of early identification and referral for children at
  risk for developmental or behavioral problems, such as through the use of health information
  technology or other means as determined by the Director of the Blueprint. (3) Provide care management and support when a patient moves to a new setting for care,
  including by: (A) providing on-site visits from a member of the community health team, assisting with
  the development of discharge plans and medication reconciliation upon admission to
  and discharge from the hospital, nursing home, or other institution setting; (B) generally assisting health care professionals, patients, caregivers, and authorized
  representatives in discharge planning, including by assuring that postdischarge care
  plans include medication management as appropriate; (C) referring patients as appropriate for mental and behavioral health services; (D) ensuring that when a patient becomes an adult, his or her health care needs are provided
  for; and (E) serving as a liaison to community prevention and treatment programs. (Added 2009, No. 128 (Adj. Sess.), § 13.)