Community Care Coordinator

Living with a chronic condition can be complicated, and draining. For those afflicted with diabetes, hypertension, asthma, or early alzheimer’s disease, for example, the constant demands of self-monitoring, preparing a proper diet, engaging in appropriate physical activity, keeping up with medications, and meeting with care-givers can be overwhelming. The challenges of navigating insurance coverage add difficulty and, at times, unnecessary expenditure. For senior citizens, who are likely to suffer from multiple ailments, the burdens of ill- health may be particularly onerous. To help area residents who need support to manage on-going healthcare or to deal with issues related to aging, Mount Ascutney Hospital and the Ottauquechee Health Foundation have jointly appointed long time local Susan Jantos to serve as Community Care Coordinator for the nine-town Ottauquechee region that includes Barnard, Bridgewater, Hartland, Killington, Plymouth, Pomfret, Reading, Woodstock, and western Quechee.

Part of the concept for Jantos’ new job is rooted in Vermont’s “Blueprint for Health,” an initiative endorsed by the General Assembly in 2006. According to the Vermont Department of Health, more than half of the state’s adults and about fifteen percent of its children suffer from chronic conditions. The Blueprint for Health seeks to improve their care, and in the long term moderate costs, with a proactive approach that facilitates preventive care and eventually reduces the need for more expensive urgent or emergency care.

Last year, Mount Ascutney Hospital successfully added a Care Coordinator position to their Provider Practice Clinic in Windsor. “My role is to look at patients’ complex health care needs and try to coordinate the services to improve their overall care,” says Registered Nurse and Certified Diabetes Educator Nancy McCullough, who took on the job. She works with Windsor’s Volunteers-In-Action, the Council on Aging, Windsor Community Health Clinic and other established resources to formulate approaches for keeping her clients as healthy as possible. “We may try to get a meal service into the home, or work with [clients] on lowering salt intake,” says McCullough of some of the particulars of her job; she might work with clients on home safety and hygiene, or help them track blood pressure or blood sugar levels and collaborate with physicians to adjust medications as needed. “It’s not a cookie cutter role,” McCullough adds, “it’s very individualized depending on what the patient needs.”

Here in the Ottauquechee region, Jantos began her job as the Community Care Coordinator on January 17. Mount Ascutney Hospital partially funded the position with monies it received from the state, to bring an important component of the Blueprint for Health’s care management philosophy to the Ottauquechee Health Center in Woodstock, which the hospital operates. The Woodstock- headquartered Ottauquechee Health Foundation provided the balance of funding. Board Member and retired surgeon Dr. Lynn Peterson collaborated with the hospital and a range of local service providers for more than a year to establish the Community Care Coordinator position. “One of the things that has struck me about the way this has come together,” he says, “is the bringing together of different organizations and interests in the community for a common purpose.”

Although an Advisory Committee is still formalizing and refining Jantos’ specific responsibilities as Community Care Coordinator, her role is modeled, in part, on McCullough’s experiences at Mount Ascutney’s Windsor location. Dr. Peterson anticipates that lessons learned from a recent Foundation study on the issues of aging and end-of-life care will also be folded in to Jantos’ work. And, he sees some latitude for her to define the job as she examines community needs in the coming weeks. “Susan has a very extensive background in medical social work with a specialty in geriatrics,” says Peterson of the new Coordinator, “she impressed [the hiring committee] as somebody who sees the whole picture…that approach is what we need.”

Jantos has worked for two decades in hospitals, home health care, hospice, skilled nursing facilities and community organizations, with an eye to understanding what elders require as they age. In her fourteen years of living in the Ottauquechee region, she’s become familiar with many of the resources here. From the outset, Jantos expects to team up with the existing local Health Information Referral Service, a telephone advisory, and with the Thompson Senior Center, a gathering place in Woodstock that provides programming and connects seniors with important services. Jantos will of course also work closely with the Ottauquechee Health Center, but says it is important to note that she will be looking to assist residents of the Ottauquechee region, regardless of whether or not they are patients at the Center. And she will draw on her knowledge of the Dartmouth Hitchcock Medical Center, where she also worked for several years. After a week of orientation at Mount Ascutney Hospital, Jantos will work with her Advisory Committee to iron out details such as where she will establish an office or offices, and how potential clients will be referred. Her services will be free of charge. Persons interested in contacting the Community Care Coordinator should watch for future communications, or can inquire through their primary care providers.