Mt. Ascutney Hospital and Health Center

Community Health Team

Community Health Team Phone #:
(802) 674-7198

Who is on the Case Management Team?

Nancy McCullough, RN, MS, CDE, Community Care Coordinator, MAHHC
Virginia Morse, RD, CDE, Outpatient Dietitian, MAHHC
Kathy Castellini, LPN, Coordinator, Windsor Community Health Clinic, MAHHC
Debbi Kelin-Smith, M.ED., LADAC, HCRS Behavioral Health, MAHHC
Sallyann Silfies, MA, HCRS Pediatric Case Manager, MAHHC
Melanie Sheehan, MCHES, Health Coach, MAHHC
Susan Read-Smith, RN, MPH, Senior Nurse Case Manager, DVHA
Karen Rich-Smith, RN, Nurse, MAHHC
Lonnie Larrow, RN, MS, Nurse, OHC
Katrin Tchana, MSW, OHC

What do we do?

  1. Coordinate community services such as:
    • HCRS/Mental Health
    • Tobacco Cessation
    • WRAP Group for Mental Health
    • Healthier Living Workshop for
    • Senior Center/Council on Aging
    • Chronic Disease
    • Meals on Wheels
    • Fuel and Housing Assistance
    • Volunteers
    • In home safety
    • Transportation to appointments
    • Dental care referrals to caregivers
  2. Insurance applications—Medicare, Medicaid, medication vouchers and assistance
  3. Home visits and phone follow up
  4. Connect with ED and inpatient discharge rounds
  5. Patient education and skill building for chronic illness, including depression, substance abuse, obesity, and anxiety
  6. Medication reconciliation
  7. Troubleshoot for chronic no shows and cancellations

Who can refer?     Anyone


Who to refer?        You know your patients’ best


Suggestions:

  • Have multiple ED and inpatient admissions
  • Chronic no show or cancel
  • Have ongoing transportation problems
  • May benefit from phone contact or home visit
  • Have complex or chronic care medical or behavioral health care needs
  • Have complex discharge planning needs
  • Need help applying for Medicaid/Medicare and other health benefits including medication
  • Have high psychosocial risk factors
  • CM services would likely reduce patient risk of adverse outcomes or readmission

How can I make a referral to case management?

1.      Complete consult in Pen Chart for Case Management
2.      Use “Phone message” in Pen Chart and pick Case Management as call back reason.  A template will populate in the “message” section and  hit the send button after choosing Nancy McCullough in send box.

This program is made possible through grant funding from the Vermont Blueprint for Health.