Care Management

• Discharge Planning - Putting together a plan of care for patients who are leaving the hospital. We work with patients, their families, their doctors, and community-based resources to meet the patient's on-going health needs. This includes helping patients receive needed care following an Outpatient or Emergency Room visit.
  
  
• Advanced Care Planning - Helping patients to understand and make choices about their Living Wills and Durable Power of Attorney.
  
  
• After medical center referrals - Providing access to Home Care and Hospice Care through Central Vermont Home Health & Hospice and Professional Nursing Services or making referrals to a Skilled Nursing Facility (Nursing Home) or an Acute Rehabilitation Facility.
  
  
• Meeting medical equipment needs - We help patients find the Durable Medical Equipment they may need once they leave the medical center. We also have a limited supply of medical equipment that has been donated to us and we will loan these items to patients as needed.
  
  
• Coordinating other helping services - Includes language interpretation for non-English speaking patients and help for the hearing and vision impaired.
  
  
• Help from the doctor's office - CVMC social workers and  nurses work with the medical practices to assist with social emergencies and/or to provide assistance for complex medical management cases.
  
  
• Providing information and education - The Department has many pamphlets and lists of resources located throughout the State of Vermont on topics including discharge planning, crisis management, drug and alcohol counseling, women's and men's abuse support, pregnancy and child rearing support, as well as a state wide list of nursing homes, in-home help lists and more.
  
  
• Utilization Review - We work with insurance companies so that the medical center receives payment for care provided. As the “agents of Medicare and Medicaid,” CVMC's Care Management staff enforce and follow the government's rules regarding Medicare and Medicaid.