Windsor Area Interagency Care Management Program

The Windsor Area Interagency Care Management team coordinates area health and human service community agencies so that they can work together efficiently and effectively to case manage individuals and families whose complex needs involve multiple agencies.

Our core members include:

  • HCRS (Health Care and Rehabilitation Services)
  • Mt. Ascutney Hospital and Health Center Community Health Team
  • SEVCA
  • Vermont Economic Services
  • Voc Rehab
  • Other agencies as appropriate in the service of families

Eligibility requirements

This program is open to individuals and families who have complex needs served by multiple agencies.

Meeting schedule

The team meets monthly, on the second Thursday of the month, from 8:30 to 9:30 am at the Windsor Connection Resource Center or at Mt. Ascutney Hospital and Health Center. The team may also be convened as needed to serve an individual or family with pressing needs.

Procedure

Any core or supporting agency in the area may identify a family in need of interagency care management. They schedule the family for this service by contacting Nancy McCullough, RN.

They submit referral information that includes the name of the referring agency, the family to be served, a brief description of the need to be met, and agencies to attend.

The referring agency completes the consent to communication and disclosure of health information (PDF) for coordination of treatment service. At the time of referral, the referring agency identifies whether the individual/family will be in attendance at the meeting.

During the meeting, the primary referral agency presents:

  • A brief history of events leading to the referral
  • The current state and condition of the individual or family
  • A discussion regarding the needs, services, and resources to be mobilized
  • A case report for families with recommendations that include an action plan, associated agencies and contact people

A follow-up presentation is done at the next interagency care management meeting to ensure that progress is made and services are on track working with the individual or family.