Reports

Health Equity is centered in the Vermont Department of Health’s strategic plan and a cornerstone of their State Health Assessment and State Health Improvement Plan. Learn more about the Health Equity Capacity Building Program’s funding opportunity in their work to reduce health disparities through community partnerships and capacity-building support.

SVMC aligns clinical initiatives and community programming to create a healthy region. Efforts are guided by the Community Health Needs Assessment, an analysis conducted every three years to determine the priority health needs for SVMC’s service area. Additionally, SVMC strategically invests in community health projects and organizations that work to meet these priority needs.

The Community Health Needs Assessment (CHNA) process serves to identify the priority health needs for the 75,000 individuals living within SVMC’s service area. Through varied methods of data collection and analysis, described in detail in the full report below, four priority health needs were identified in 2021.

Mental Health Supports
Promotion of Healthy Behaviors and Primary Prevention Activities
Accessibility of High-Quality, Convenient, and Affordable Care
Substance Use Prevention, Harm Reduction, Treatment, and Recovery Resources

A Community Health Needs Assessment (CHNA) is a process that non-profit hospitals complete every three
years in partnership with community-based organizations to learn more about the significant health needs in
the greater community. These valuable insights inform strategic investment and guide community programming
to improve the identified priorities. The University of Vermont Health Network- Porter Medical Center (UVMHNPMC) and the 12 members of the 2024 CHNA Steering Committee collaborated on the 2024 CHNA for its designated Health Service Area of Addison County.

2024 CHNA GOALS
• To conduct an inclusive and high-quality assessment
of community health needs and assets across the
lifespan in Addison County, through the lens of health
and racial equity.
• To partner with diverse stakeholders resulting in: 1) consensus of priority needs to address; 2) shared
buy-in for implementation strategies; 3) support of complimentary community initiatives and
assessments.

• To conduct an inclusive and high-quality assessment
of community health needs and assets across the
lifespan in Addison County, through the lens of health
and racial equity.
• To partner with diverse stakeholders resulting in:

1) Consensus of priority needs to address
2) Shared buy-in for implementation strategies
3) Support of complimentary community initiatives and
assessments.

At Mt. Ascutney Hospital and Health Center (MAHHC),our Community Health Department offers programs that
help people afford necessary health services, learn skills to manage chronic disease, focus on wellness in the family and community, provide transportation, and much more. We welcome and invite you to read this 2023 CommunityBenefits report, which shares our programs and progress for fiscal year October 1, 2022 through September 30, 2023. Along with our progress updates, we wish to than the hundreds of partners woven
throughout our vast network of social service organizations that support and advance the work of improving the lives of those we serve.

This report presents the findings of a comprehensive 2024 Community Health Needs Assessment (CHNA) for residents of Windham County and surrounding towns within the Brattleboro Memorial Hospital (BMH) service area. It identifies significant health needs (SHNs) in our community and establishes priorities that the BMH Senior Leadership Team has chosen based on an analysis of the findings. An Implementation Plan will be developed in the coming months to address the established priorities.

This report presents the findings of a comprehensive 2024 Community Health Needs Assessment (CHNA) for
residents of Windham County and surrounding towns within the Grace Cottage Family Health & Hospital service
area. It identifies significant health needs (SHNs) in our community and establishes priorities that the Grace Cottage Medical Executive Team and the Senior Leadership Team have chosen to address, based on an analysis of the findings. An Implementation Plan will be developed in the coming months to address the established priorities.

SPRINGFIELD HOSPITAL 2025 COMMUNITY HEALTH NEEDS ASSESSMENT
IMPLEMENTATION PLAN
(Approved by the Springfield Hospital Board of Directors 2-10-26)

Springfield Hospital, in conjunction with North Star Health, conducted a Community Health Needs Assessment (CHNA) in 2025. This Implementation Plan is a companion piece to the needs assessment report, serving the period from 2025-2028. This Implementation Plan outlines a course of action for how Springfield Hospital plans to address the top community health priorities. Both the Community Health Needs Assessment and the Implementation Plan can be found at https://springfieldhospital.org/community-health-needs-assessments/

There were six key community health issues identified in the report (See pages 3 to 6 of the CHNA). Springfield Hospital will collaborate with our care partners to implement initiatives and programs that work to meet these objectives to improve health in the community.

1) AVAILABILITY OF PRIMARY CARE AND SPECIALTY MEDICAL SERVICES

• Goal: Ensure timely outpatient follow-up for hospital patients through partnerships.
• Actions:
• Discuss with our primary care providers if it is feasible to reserve expedited post-discharge appointment slots for our emergency room in-patient, and specialty care patients.
• Research the feasibility of a “follow up clinic” to bridge the gap i.e. waiting time, between discharged hospital patients and primary care partners for follow-up visits.
• Strengthen referral tracking: centralized care coordination team follows referrals until visit is completed.
• Research solutions to EMS transport challenges.
• Partners: North Star Health, other primary care providers, specialty groups, and transport groups.

2) COST OF HEALTH CARE SERVICES, INCLUDING PRESCRIPTIONS, COPAYS, AND INSURANCE

• Goal: Reduce financial barriers for patients discharged from the emergency department (ED) and inpatient unit (IPCU) to allow for more access to follow-up care and medications.
• Actions:
• Review Financial Assistance Policy for readability, updated as approved by the Board of Directors.
• Promote availability of Springfield Hospital Financial Assistance program.
• Embed financial/benefits navigators in ED and discharge planning to assist with Medicaid/marketplace enrollment and manufacturer assistance.
• Research options for providing a hospital-administered short-term medication co-pay/bridge fund and 7–14-day discharge medication supply for high-need patients.
• Develop protocols and pathways to community clinics and other resources that accept sliding scale/charity care.
• Collaborate on public relations efforts with other organizations to raise awareness about free vaccines, insulin cap costs, and other community support services.
• Partners: North Star Health, patient advocacy nonprofits.

3) SUBSTANCE MISUSE AND THE AVAILABILITY OF SERVICES FOR PREVENTION, TREATMENT, AND RECOVERY

• Goal: Increase initiation of evidence-based opioid use disorder (OUD) treatment and connection to recovery services from the hospital.
• Actions:
• Work with local agencies to help overcome gaps in services – detox, residential treatment, and recovery housing.
• Employ peer recovery coaches in ED/inpatient units to support engagement and navigation to treatment/housing/employment resources.
• When appropriate, distribute naloxone kits at discharge and provide brief training; partner with community harm-reduction organizations for syringe services/mobile harm reduction expansion.
• Explore opportunities for medication assisted programs in the ED.
• Develop protocols and pathways to community clinics and other resources.
• Support the development of a multi-disciplinary team to develop protocol for diversion to treatment.

• Partners: addiction treatment providers, pharmacies, public health, North Star Health.

4) AVAILABILITY OF MENTAL HEALTH SERVICES

• Goal: Improve timely access to behavioral health for hospital patients and community.
• Actions:
• Explore the addition of outpatient mental health treatment to Springfield Hospital range of services.
• Integrate behavioral health clinicians and peer recovery specialists into ED and inpatient teams for screening, brief intervention, and warm handoffs.
• Enable ED-initiated tele-psychiatry consults and scheduled outpatient behavioral health follow-ups via partner clinics or telehealth.
• Connect with community mental health providers to discuss the feasibility of reserving rapid access slots for hospital referrals.
• Support the development of a multi-disciplinary team to develop protocol for diversion to treatment.
• Explore opportunities for CMS waiver regarding limitations on distinct part units for critical access hospitals.

• Partners: community behavioral health agencies, tele-psychiatry vendors, county mental health authority, peer-run organizations, EMS, law enforcement.

5) AFFORDABILITY AND AVAILABILITY OF DENTAL CARE SERVICES

• Goal: Connect hospital patients with dental care through partnerships.
• Actions:
• Review and update memorandum of understanding (MOU) with community dental clinics, dental schools, and mobile dental units to accept prioritized hospital referrals (urgent dental needs) and provide sliding-scale care.
• Create a dental referral pathway embedded in discharge planning for ED patients presenting with dental complaints; provide temporary pain/antibiotic relief and transport assistance if needed.
• Collaborate with community resources to increase awareness for assistance they offer in accessing dental services.

• Partners: local dental clinics, dental schools, mobile dental providers, community health centers, oral health nonprofits.

6) SOCIOECONOMIC CONDITIONS AFFECTING HEALTH AND WELLBEING SUCH AS LACK OF SAFE AND AFFORDABLE HOUSING, TRANSPORTATION, AND ACCESS TO HEALTHY FOODS

• Goal: Improve Social Determinants of Health (SDOH) support for hospitalized and ED patients to reduce readmissions and missed care.
• Actions:
• Standardize SDOH screening at admission/ED visit and embed social need navigators/case managers to arrange referrals for housing, transportation, food, and benefits.
• Create standing agreements with local housing agencies/nonprofits for prioritized placements for medically vulnerable patients; research the feasibility of creating a fund for short-term emergency housing for discharge when needed.
• Contract with non-emergency medical transportation providers and voucher services; create connections with volunteer ride programs for follow-up visits.
• Continue to participate in offering monthly food deliveries to assist area residents (Veggie Van Go).
• Support local housing and childcare initiatives.
• Work with a community coalition of multi-disciplinary agencies to align SDOH to improve physical and mental health care outcomes.

• Partners: housing authorities, transit providers, food banks, social service agencies, community clinics.

For over 20 years, Rutland Regional Medical Center (RRMC) has conducted a Community Health Need Assessment (CHNA), which has prioritized Rutland County efforts in partnership with the hospital to improve the health
and wellbeing of area residents.The assessment is completed and published on a three-year cycle with continual collaborative effort to address the health areas of greatest need within our community. With a foundational focus of working in concert with the community and many regional partners, the CHNA aims to better understand how we can improve the health of our region. This assessment includes statistical data, survey data from community members, community leaders, and medical providers, and focus group data to help further define needs in each priority health area.