Meet people where they are. More than a catchphrase, this strategy of connecting with individuals in a way that’s effective for them lies at the heart of the way many of us work, particularly those of us who serve or care for others as our vocation. It can mean physically where they are, or in terms of connecting with their background, knowledge or experience, and it’s a common theme we hear when we ask providers about their philosophy of care.
Take this example, presented by Warren McDermott, DNP, who joined our Primary Care team in November 2023: “Building rapport with patients is incredibly important, aligning with their values and goals,” says Warren as he describes helping patients make long-term behavioral changes, such as smoking cessation. “This helps to get buy-in for changes and reduces the risk of wasting our time and their time. Together we make sure we’re focusing on things they actually care about.”
Greater Gifford similarly focuses on the things our patients and community really care about, by listening. In September 2023, Gifford continued its annual Community Listening Tour with stops in Chelsea, Randolph, Rochester, and South Royalton, Vt. Along the tour, leaders from Gifford invited partners Capstone Community Action, Clara Martin Center, and Tri-Valley Transit to share information about their programs and services and hear feedback from residents.
Among those on hand was Melanie Gidney, executive director for Clara Martin Center, a nonprofit based in Randolph that provides acute and long-term behavioral health care services throughout the greater Orange County area. The center serves children, families, and individuals coping with mental health challenges, emotional stress, mental illness, alcohol and other substance-use problems.
Gidney and her colleagues meet people where they are: sometimes in an office setting but often in schools and private homes; with transportation; in meeting day-to-day needs, such as grocery shopping for healthy foods or doing laundry; and in keeping them wrapped in services and care through connection with other partners, like Gifford.
We recently caught up with Gidney to talk about her agency’s role in our community, our partnership, and what she sees as a critical component of that partnership: care coordination.
“Care coordination is essential—the left hand and the right hand need to know what’s going on to best serve folks,” she says.
Gifford and Clara Martin coordinate care around medication-assisted treatment, nursing to address complex medical needs, and managing chronic care conditions to include involvement of primary care providers where necessary.
Gidney expanded on the need for coordination in the context of prevention.
“We have staff who are connected with Gifford care coordinators and communicate about high-needs, high-risk clients, those we serve that Gifford also serves, some of whom end up in the Emergency Department, and what can we do to prevent that level of care need and help these individuals be more successful in the community.”
Gidney touched on several other ways Gifford and Clara Martin connect: by sharing physical space at the Chelsea Health Center—a model for co-location and collaboration, where we can guide “warm handoffs, making sure people don’t fall through the cracks”; by ensuring Clara Martin clients are able to access the fresh fruit and vegetables available through Gifford’s monthly VeggieVanGo program; and generally by taking a whole-health approach, utilizing the strengths of each organization for the betterment of community members.
That starts with leadership.
“We have a very strong relationship,” says Gidney, describing her collaboration with Gifford President and CEO Dan Bennett. “I know who Dan is. I feel like I can call him and that we can work together to address issues in our very rural area, of which we are the two leading health care entities. It’s incumbent upon us to be really strong partners and make sure that we’re meeting the needs of the people we serve, and that we stay in our lanes of specialty.”
That high-level collaboration extends beyond Bennett, to include quarterly senior leadership meetings between the two organizations to discuss issues facing our community, meetings that ramped up during COVID and continue today.
“Our missions are similar but allow us to be specialists in our necessary areas, and to use those specialties to the best of our ability to meet the changing needs of our community,” says Gidney.
Accessibility is key to meeting the care needs of a community, a theme touched on time and again during Gifford’s Community Listening Tour, and the demand for mental health and substance-use services has only amplified since COVID. Clara Martin Center is in the early days of a special program to meet that increased demand with same-day treatment.
“The acuity, the challenges people are facing are more difficult, more complex, and we need to do a better job at meeting that need,” says Gidney. “We know that when somebody needs mental health or substance-use treatment, the earlier you can engage them when they’re asking for help, the more likely they are to be successful in treatment.”
To that end, Gidney and her team have been working on a grant-funded initiative that enables the center’s clinicians to provide same-day access, same-day assessment—no appointment necessary—several days a week at locations throughout their catchment area, including Randolph.
“We’re trying to eliminate that [accessibility] barrier and let people just walk in,” says Gidney. “This program provides better access, easier access, and we’re really meeting them when they’re ready and able to engage.”
More Action to Address Barriers
Like Clara Martin Center, longtime Gifford partner Capstone Community Action participated in Gifford’s 2023 Community Listening Tour. The organization, which serves low-income residents, likewise has partnered with Gifford in a variety of ways over the years, in terms of direct service but also as part of broader community efforts.
“We have worked with Gifford staff to serve mutual participants, provide community suppers, served on community networking teams to address homelessness and systems service issues, and shared outreach around services offered through both organizations,” says Capstone’s Linda Anderson, director of family and community support services.
Capstone’s work in the community intersects with Gifford by providing services to support individuals’ basic needs that directly and indirectly impact health outcomes. This includes rental housing counseling for individuals who are homeless or at risk of homelessness; support to access food; energy assistance and weatherization services; and Head Start and Early Head Start, programs that help families connect to dental and health care for their children, and more.
“All of these services support the health and wellbeing of individuals, many of whom are served through Gifford,” says Anderson.
Improving access to care is top of mind for Capstone, too.
In addition to making referrals to Gifford for health care and substance-use treatment, Capstone’s Early Head Start program helps families access health and dental services. And Community Rides Vermont, a pilot program that began as a Capstone initiative, provides transportation to low-income community members on a sliding scale.
The latter, for example, “can support people getting to appointments at Gifford’s services in the Berlin area,” says Anderson.
Another Gifford partner, nonprofit Tri-Valley Transit (TVT), shared the mic during the Community Listening Tour to discuss transportation.
“We really appreciate the support and involvement that Gifford provides,” says TVT Community Relations Manager Mike Reiderer. “Being a part of community conversations and working together to address challenges is key to providing the best services possible in our community, and Gifford has been a wonderful partner with us for many years.”
“TVT’s public bus routes serve Gifford’s Randolph-based locations, including Strode Independent Living, Menig Nursing Home, and Kingwood Health Center, in addition to [Gifford Medical Center] being one of our most utilized stops on our local routes.”
In addition to its bus service, TVT provides Dial-a-Ride throughout our region.
“TVT’s Dial-a-Ride program provides door-to-door transportation for eligible residents living in our Orange and Northern Windsor County service area, including residents over 60 years old, people with disabilities, and Medicaid members who qualify for transportation assistance,” Reiderer says. “These programs offer additional access to Gifford’s clinics in Bethel, Sharon, Chelsea, and Rochester.”
While TVT has a clear, literal focus on getting people where they need to go, all Gifford partners share a commitment to breaking down barriers and connecting our community with care and services to optimize their health and wellness. It’s long been who we are—Gifford since 1905, Capstone Community Action since 1965, Clara Martin Center since 1966, and Tri-Valley Transit (formerly Stagecoach) since 1976. Together, in 2023 and beyond, we are meeting people where they are, wrapping them in services, and strengthening our community.
For more information about our partners, visit:
claramartin.org
capstonevt.org
trivalleytransit.org
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