Vermont Business Magazine Community Health is introducing a new Geriatric Program, a comprehensive program tailored to the unique medical and behavioral health needs of older adults. The goal of the program is to improve quality of life for seniors so they can live independently and safely and be connected to the resources that will help them manage chronic conditions and prevent emergency department visits through prevention, awareness and education.
Community Health patients age 60 or older, who have more complex needs and may benefit from additional coordinated support, should speak with their primary care provider about the program.
The program is designed for individuals experiencing:
- Memory changes or confusion
- Falls, balance concerns or changes in mobility
- Multiple chronic conditions or complex medical needs
- Medication safety concerns or multiple medications
- Caregiver stress, social concerns or difficulty with daily activities
How It Works
Your provider will send a referral to the Geriatric Program and care begins with a complete comprehensive assessment to identify medical, functional, cognitive, social and safety-related needs that might not have been previously identified. A care manager will conduct a home visit for a safety evaluation and determine if there are barriers to an individual’s health.
An Annual Wellness Visit will focus on preventive care and maintaining a healthy lifestyle where health status and risk factors are discussed and a personalized plan is created to ensure that preventive screenings are scheduled and chronic conditions managed.
After assessments, follow-up visits and care planning are completed, patients transition back to their primary care provider with recommendations, an updated care plan and referrals or supports that may need to continue.
Support Every Step of the Way
The program is comprehensive and coordinated, assisting patients, families and caregivers create a care plan focused on staying safe, preventing complications and managing ongoing health needs. The coordinated care includes:
- Medication review to reduce the risks associated with drug interactions and unnecessary medications
- Care coordination with a dedicated care manager
- Referrals to specialists like cardiologists and neurologists, physical and occupational therapists and mental health support
- Connections to social service support for housing, finances and other non-medical needs
- Advance care planning, including establishing directives for patients and their families to reflect a person’s end of life care wishes and values
At Community Health, we care for the whole person – physical health, emotional well-being and daily life – so older adults can stay as healthy and independent as possible.
For more information about Community Health's Geriatric Program, patients should contact their primary care provider or Patient Access at 8092-779-9169.
About Community Health
Community Health is Vermont’s largest Federally Qualified Health Center (FQHC), providing primary care, pediatrics, behavioral health, dental, eye care, and pharmacy services across multiple locations, including Brandon, Castleton, Rutland, Shoreham, and West Pawlet. Express Care centers, open seven days a week, are located in Rutland and Castleton.
Learn more about services, locations, hours, and career opportunities at CHCRR.org or contact Patient Access at 802-779-9169.
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