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Blueprint Community Health Teams

Good Health Happens in Communities

Good medical care happens in a doctor’s office, but good health happens in a community. Community Health Teams supplement the services available in Patient-Centered Medical Homes and link patients with the social and economic services that make healthy living possible for all Vermonters.

Community Health Teams Supplement Medical Home Services

Each of Vermont’s Health Service Areas designs a Community Health Team to meet the needs of the local population. The Community Health Team services may include:

  • Patient-centered medical home patient population / panel management and outreach
  • Individual care coordination
  • Brief counseling and referral to more intensive mental health care as needed
  • Substance use disorder treatment support
  • Condition-specific wellness education

Community Health Teams Customize Wellness Services for Local Needs

The services and staff may be co-located with the practices (“embedded”) or centralized at a convenient location. Actual service configuration, staffing, and location are determined by local leaders based on community demographics and health needs, identify gaps in available services, and the strengths of local partners.

Barrier-Free Wellness

Community Health Teams are funded by Medicaid, Medicare, major commercial insurers, and some self-insured businesses, based on the total number of Medical Home patients in the Health Service Area. Access to Community Health Teams is offered barrier-free to patients and practices. This means no co-payments, no prior authorizations, and no billing. Without these limitations, care can be customized to help people how, when, and where they need it.

More details about how Community Health Teams are paid for and staffed may be found in the Blueprint Manual, located with the Blueprint's Implementation Materials.

Connecting with Your Community Health Team

Most referrals to Community Health Teams are made by providers in Blueprint Patient-Centered Medical Homes. In addition, each Community Health Team builds referral relationships with the local:

  • Hub and Spokes that treat opioid addiction
  • Specialty health practices that participate in the Pregnancy Intention Initiative
  • Medical, social services and community-based organizations

If you think that you or someone you care about could benefit from Community Health Team services, please ask your primary care provider. Community-based organizations looking to build closer working relationships with their local Community Health Team can contact the area Project Manager or Community Health Team lead.