Transitional Care nurses in Bennington…catalysts for integrated care delivery in their community. By Billie Lynn Allard

At Southwestern Vermont Health Care, located in Bennington Vermont, we have been on an exciting journey for the past 3 years as we seek ways to improve the health of our population. As healthcare reform continues to evolve, the shift from inpatient care delivery to outpatient has provided an opportunity for us to consider shifting acute care resources to meet individuals where they are now.  In 2013, a group of three Clinical Nurse Specialists stationed in the Intensive Care Unit, Telemetry Unit and Emergency Departments attended a Transitions of Care training program at the University of Pennsylvania based on the successful research of Mary Naylor, PhD, RN and her team.  Since that time, all primary care practices in our community have partnered with Transitional Care Nurses (TCN), identifying high risk patients with chronic diseases and assisting with education, symptom identification, and medication management.  The nurses met with community partners to identify where there were gaps in care, communication, coordination and available resources. Our goal was to improve integrated care delivery for the population we serve avoiding duplication or competition. Expert clinical nurses navigating with patients and their families from one care setting to the next could clearly identify opportunities for improvement.  Over the past three years with support from hospital leadership and Vermont Health Care Innovation Project grant funding, we have been finding creative ways to bridge the gaps for our community.  A Community Care team composed of clinical partners, and community agencies that assist frequent users of the Emergency Department with mental health and addiction, meets monthly to discuss specific patients who have consented to participate in this collaborative approach to care.  These patients seeking care sometimes three times per week are not appearing to get their needs met and often may be better served by assistance with finding employment, safe housing, adequate food and social support.  Having all partners at the table has been pivotal in our collective ability to help this population of patients’ live healthier, happier lives.  An added bonus has been the development of strong relationships and improved understanding of the role we each play and the recognition that we can be so much more effective as a team than we are as individuals.

Hospital based nurses now functioning across the care continuum have a renewed appreciation for the reality in long term care and rehabilitation settings and at home and in provider office settings. Suddenly we recognize how little care is delivered in the hospital setting and how much more happens outside of our walls.  Patients do not understand their discharge instructions, are overwhelmed and confused about their medications and many need food, water and shelter before they can even begin to learn about managing their chronic disease.  The stark realization of the role of social determinants of health is clear and the urgent need for a community social worker to assist with helping individuals get connected with the right resources to meet their needs.  Our vision includes the creation of community network of integrated social workers handing off to one another, assuring necessary steps are taken for health care coverage, safe housing and access to medications, heat and food.

On this journey, we see clearly the challenges of primary care providers, as they manage large panels of patients, with limited time and resources. Medical Home implementation has been a huge source of support in our community and we have partnered with them to see how we can best collaborate and work together.  Primary care providers requested access to clinical pharmacists that could assist them with medication management, reconciliation and consults related to polypharmacy.  Clinical pharmacists have partnered with four practice settings on a pilot project to be one more resource for patients and providers and assure improved medication adherence and understanding.  They may see patients in the hospital, primary care office or even at home.  Clinical pharmacists now have the advantage of witnessing what the challenges are outside of the hospital….in the real world.

In 2013, a pilot project was initiated in one medical home practice, embedding a Certified Diabetes Educator (CDE) nurse to see patients in the office to assist with education and management of their diabetes with promising results. This program expanded to other practices with evidence of decreased A1C results as well as patient and provider satisfaction.  In March of 2016, we expanded this program to include an additional CDE who is available to partner with other provider offices and see patients as well as being available for consultation at the hospital and skilled nursing facility.  Creation of an integrated diabetes team includes dieticians and certified diabetes educators seeking to improve the health of our population.  A year- long pre-diabetes program sponsored by the YMCA is underway with enthusiastic participation from community members.

At Southwestern Vermont Medical Center, our rate of readmissions coming from skilled nursing facilities was higher than benchmarks. The Transitional Care team looked for evidence based practice on what might help and found INTERACT ™.  This system of empowering nursing assistants to speak up when they notice subtle changes in condition, report them to nursing who then reports them to a physician or nurse practitioner, can have a major impact on managing patients at the Skilled Nursing Facility (SNF) without transfer to the hospital.  A Stop and Watch process to assess certain patients more frequently with documentation in the medical record and updates to the plan of care can also positively impact meeting regulatory requirements.  Our experience includes sustained decreases in readmissions from our affiliated SNF and are leading implementation in all of the other facilities in our service area.

One by one, we are looking beyond the hospital walls and bridging gaps in care coordination in our community. We all concur that it is the most rewarding and exciting work of our careers.  We are meeting the triple aim as we have decreased hospital admissions by 68% and ED visits by 29% for the patients before and after TCN services, thus decreasing the cost of care. Standardization of COPD, CHF and Diabetes care is improving quality outcomes demonstrated by pulmonary rehabilitation statistics and AIC levels. Patient surveys show that our patients and their families appreciate the support of this program and have an improved understanding of their illness and medications.

Quarterly meetings have been scheduled to assess our progress and chart the course for the future. Expansion of who is at the table continues to evolve as layer after layer is uncovered.  A recent community forum was encouraging as town leaders, legislators, educators, and representatives from across our community came together and listened to a panel discussion of what is happening right now.  We feel blessed to be in an environment open to change, excited about innovation and determined to continue down this journey of creating an accountable community.  We feel fortunate to be involved with the Accountable Communities for Health teams from across the state of Vermont, who are on this same journey. The opportunity to network with them, build relationships and benefit from their lived experience in their community is priceless.  We are happy to share our lessons learned with others as we lead this country in a positive direction, focused on improving the health of our citizens.






Blog on food insecurity and how ACH can play a role. John Sayles, Vermont Foodbank

September 27, 2016

It seems to me that the world of health care is changing faster that many of us realize, and in ways that many of us don’t fully understand, including me. My hope, however, is that we are truly at the start of a transformational shift from treating the individual to a focus on the community’s well-being. This will involve nontraditional partnerships and collective action – what I see as the promise of Accountable Communities for Health (ACH) in Vermont: bringing together people, institutions and programs that impact the social determinants of health and holding ourselves collectively accountable for the health and well-being of a whole community. This is a complex undertaking, and the recipe for success requires a commitment to step outside our comfort zone.

As CEO of the Vermont Foodbank, hunger is my “lane.” Forty years ago food banks thought we could end hunger by capturing all the wasted food we saw and delivering it to people who couldn’t afford enough for themselves and their families, usually through existing community groups and faith-based organizations. However, the community need outpaced the food banks’ capacity to access and distribute more food, and we struggled to understand why we weren’t making sustained progress. With experience and more sophisticated understanding of systems, we’ve realized that hunger can’t be solved without understanding and addressing the complex interconnections of our neighbor’s lives.

Yet we still struggle to understand the interconnectedness and interdependence of the social/political systems we have constructed over the years – a hodgepodge of stovepipes you might say. Access to health care, food, housing and meaningful work is essential to family stability and health, and many of our neighbors can’t fulfill those needs on their own. Programs designed to help often separate these interdependent needs into “program” areas that create another stovepipe. We’ve designed systems that don’t do what we really want them to do – help families achieve stability.

The systems need to change, but before that can happen we need to understand why the systems don’t work. Accountable Communities for Health are an opportunity to take some steps forward along that path. Inviting nontraditional partners (like the Vermont Foodbank) to the table is a first step. It takes courage. You may not think the community housing agency or the regional planning commission understands the work you do. And you’re probably right. Spending the time to understand each other takes patience and persistence. Building a trusting relationship with your partners and maintaining it takes resilience. But with the right people around the table you can start understanding those complex interconnections and interdependencies that stand in our way. You’ll need everyone’s commitment to the shared ACH goal of community health and well-being.

This work is beginning to happen around the country. We’re excited to be part of a pilot right here in Vermont, funded by Feeding America ( that is ground testing the theory. It also happens to be an ACH that is part of the work we are all doing together. You can learn more about the work we’re doing at

Bring your resources, learning and perspective to the table – and leave your organizational ego at home. Discover how our social and political systems interconnect. Recreate adaptive systems that understand those connections. Be willing to change what you do to help the whole community reach its shared goal. You will see lots of barriers at first (regulations, policies, “the way we’ve always done it,” other partners’ stubbornness) but don’t give up. I can’t solve hunger without you, and we can’t create community health and well-being without each other.


Peer to Peer Musings

Upper Connecticut River Valley- From Steve Voigt, Executive Director

The Upper Connecticut River Valley of Vermont and New Hampshire is home to Dartmouth College and the Dartmouth-Hitchcock Medical Center—major players in the regional economy and the local health system. While there are pockets of poverty in this community of 140,000, residents generally are above average in education, income, and health status. But the region faces other challenges, including high per-capita health costs, rapidly declining Medicaid reimbursements, rising unemployment, an aging population. Additionally, the region’s rural nature creates challenges for accessing primary care.

Aspiring to a healthy and sustainable local economy, leaders from Dartmouth challenged Upper Valley residents to join together in addressing high healthcare costs and imagining a stronger future for the entire region—and they turned to ReThink Health for technical assistance. We worked with local champions to launch an initial planning team that included leaders from major regional employers, the social service sector, and members of the Upper Connecticut River Valley community, Dartmouth College, and Dartmouth-Hitchcock Medical Center. Working closely with this team, ReThink Health helped launch a series of community dialogues, engage key stakeholders, and initiate regular meetings to think through challenges and guide progress toward a genuinely shared strategy for collaborating to transform the region.

We also partnered with members of the leadership team to interview key regional stakeholders to both identify potential leaders and inform the design of a strategic approach to improving health and health care in the Upper Connecticut River Valley. That effort resulted in a white paper, which was distributed throughout the community to help build greater interest in the initiative.

Rethinking the Regional System for Health

ReThink Health also helped the group design and execute two major gatherings of more than 80 community leaders, first to formulate a coherent vision for the region, and then to explore change strategies and articulate areas for innovation. The ReThink Health Dynamics Model was an important tool in this process. It helped the community focus on priorities related to behavior, coordination of care, and payment reform—particularly global payments. The ReThink Health team supported the design of a collective decision process so that, from these community gatherings, the initial planning team launched additional teams responsible for leading different aspects of the effort going forward.

Now in Phase 2, this long-term initiative has begun moving into implementation, including the creation of a permanent office and the hiring of key staff. ReThink Health helped the initial planning team design a structure and process for the long-term stewardship of resources in the region, including mechanisms for citizens to participate in setting priorities and leading change. Further, a large-group gathering in late 2013 saw the launch of three “circles of innovation” working groups, which were formed to lead efforts on:

  1. Coordinating care in the Upper Valley, including between medical care and social services;
  2. Engaging citizens and workplaces in healthy behavior programs to improve population health; and
  3. Altering the payment system in the region toward global payments, and creating a system for capturing savings from change efforts and reinvesting in upstream, health promoting activities.

As the initiative evolves, local leaders are taking greater ownership over the project and developing new organizational and governance models. They also are continuing to work with ReThink Health to focus their efforts on designing, implementing, and evaluating programs that will provide system-wide effects in targeted areas of interest

Note:  I have posted our governance charter on the ACH site page as a resource for other sites.