Windsor Area Interagency Care Management Program

Purpose / The purpose of the Windsor Area Interagency Care Management team is to coordinate area health and human service community agencies to provide an efficient and effective mechanism to jointly case manage individuals and families whose complex needs involve multiple agencies.
Core Members / Mt.AscutneyHospital and HealthCenter Community Health Team
SEVCA
Voc Rehab
Vermont Economic Services
HCRS
Other agencies will be included as appropriate in the service of families.
Eligibility Requirements / Individuals and families with complex needs served by multiple agencies.
Meeting Schedule / The team will meet monthly, the second Thursday of the month, from 8:30 AM to 9:30 AM at the WindsorConnectionResourceCenter or Mt.AscutneyHospital and HealthCenter.
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 will schedule the family for this service by contacting Nancy McCullough, RN, at (802) 674-7198, or at . They will submit referral information that includes the name of the referring agency, family to be served, a brief description of the need to be met and agencies to attend.
The referring agency will complete the consent to communication and disclosure of health information for coordination of treatment service (please see attached). At the time of referral, the referring agency will identify whether the individual/family will be in attendance at the meeting. During the meeting, the primary referral agency will present a brief history of events leading to the referral; current state and condition; a discussion will be held regarding needs, services and resources to be mobilized; a case report will be written and given to families with recommendations that include an action plan, associated agencies and contact people.
Follow up presentation will be done a the next interagency care management meeting to ensure that progress is made and services are on track working with the individual or family.

REFERRAL TO WINDSOR AREA INTERACENCY CARE MANAGEMENT TEAM

Date:

Referring Agency
Agency:Telephone:
Address:Fax:
Email address:
Client Information
Name:Telephone:
Address:Messages can be left with:
Email address:
Brief Description of Need
AGENCIES REQUESTED FOR ATTENDANCE
□Mt.AscutneyHospital and Health □Children Integrated□Vermont Adult
Center Community Health TeamServicesLearning
□AreaParentChildCenter (Specify):□Supported Housing (Specify):□Council on Aging
______□HCRS
□Vermont Economic Services□Division Family Services□SEVCA
□Department of Vermont Health Access/□Division of Probation and Parole□Voc Rehab
Vermont Chronic Care Initiative□School (Specify role): ______
□Other (Please specify)

Please indicate if the family will be in attendance at the meeting□Yes□No

□Consent to communication and disclosure of health information for coordination of treatment services has been signed by involved individual.

Referral to Interagency Care Management Program

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Date Team Met:

Team Members Present
Name:Name:
Agency:Agency:
Email address:Email address:
Name:Name:
Agency:Agency:
Email address:Email address:
Name:Name:
Agency:Agency:
Email address:Email address:
Action Plan
ActionResponsible PersonTime Frame
Follow Up
Follow up Scheduled for
DateTime

Patch/Windsor Area Interagency Care Management ProgramRev 3-27-12