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Agenda for the Payment Implementation Workgroup meeting Feb. 5, 2025

The information found in this Community Health Worker Annual Report describes program performance between January 2020 and June 2021. The report is meant to be a resource for the Dartmouth—Hitchcock Health system and partners.

The Community Health Worker Program began in August 2016 by working with patients with a history of high Emergency Department (ED) utilization. After a successful pilot program with two Community Health Workers (a 50% decrease in average ED visits), D-H added CHW services for primary care patients beginning July 2017. Availability of CHW services for D-H employees also began in July 2017.

To identify patients with health related social needs, a SDoH screening tool was piloted from September 2017 to December 2017, initially tested with Medicaid patients receiving primary care with D-H Heater Road providers. It has been used at primary care practices located at Heater Road since January 2018 to identify patients with actionable social determinants of health issues which are then addressed by a CHW. Since this time, screening practices have expanded to all primary care locations at Dartmouth-Hitchcock Health, with current efforts focused on expanding screening beyond the Medicaid population to include adult patients, regardless of insurance type. The D-H Community Health Worker workforce has expanded in order to meet the needs of our patients as they are identified by the screener and providers.

Minutes from the Blueprint Executive Committee meeting on Jan. 16, 2025

Slides that present information about years one and two of the CARE series of webinar trainings. The presentation was given to the Executive Committee on Jan. 16, 2025.

Data analysis of the second-year chart review in the CHT expansion pilot. Slides were presented at the Jan. 16, 2025 Executive Committee meeting.

Executive Committee Agenda for Jan 16 2025

A conversation on perinatal substance use and the key role pediatric-serving medical homes play in supporting families during this critical period. Includes:
• Vermont data
• Screening for perinatal substance use in the child health visit, including best practices and challenges in workflow and documentation
• The Plan of Safe Care and mandatory reporting expectations
• Referrals and resources for children and families experiencing perinatal substance use

An exploration of Vermont Developmental Surveillance, Screening and Referral approach, including tools, online screening options and partnerships between medical home, Help Me Grow and Children’s Integrated Services (CIS). Developmental and behavioral screening is a whole-population strategy to improve child health outcomes. Screening, together with routine developmental surveillance, provides an opportunity to monitor if a child is learning age-appropriate skills and to identify any developmental or behavioral concerns as soon as possible, enabling intervention during the most critical periods of development. When young children are not screened systematically, opportunities for early identification, intervention, and treatment may be delayed. Early identification of children at risk for developmental delays is an integral function of the primary care medical home.

A conversation on how the medical home and Vermont’s early childhood system can partner more closely and effectively in service of children and families. Key partners and programs in the early childhood system: Parent Child Centers, Children’s Integrated Services (CIS), Help Me Grow (HMG) Vermont, and more. Examples of successful integrative models, including DULCE.

Grounding the year-long series in a relational approach to working with children and families, the why and how of child and family engagement, Bright Futures Guidelines, and the promotion of social-emotional health throughout pediatrics, including a brief overview of the Touchpoints Approach.