The Community Health Team at The University of Vermont Medical Center, provides a number of services, including:

  • Conducting health screening assessments
  • Helping you manage your medications
  • Connecting you with community/financial resources
  • Tobacco Cessation Services
  • Helping you sustain positive health behaviors like eating well, becoming more active and managing stress by connecting you to our series of free Healthier Living workshops.

Community Health Team Services

Getting Results

Six months after leaving the Community Health Team, 72.5% of patients with diabetes maintained or lost weight, and 43.3% of patients with diabetes improved their cholesterol.


"Just had a visit with my doctor. Weight was down six pounds from last visit. Blood Pressure was 125 over 65. Cholesterol was much better than it has been. He was also happy to hear about the progress in smoking. Overall he was pretty happy with my progress, which of course made me happy, too.  Thanks for all of your help." — Community Health Team Patient

Meet the Community Health Team

A patient-centered medical home fosters a team approach to improving health outcomes for patients. The Community Health Team is a group of professionals who will give you the tools and support you need to reach your goals.

Community Health Team members provide expertise in helping you manage your chronic condition. Each member brings a level of expertise in different areas to help you be as healthy as possible.

Our Nurse will:

  • Conduct a health assessment and screening
  • Work with you to develop strategies to manage your condition
  • Help you manage your medications
  • Provide diabetes education
  • Provide guidance for healthier living
  • Help you set goals to improve your health
  • Provide coaching to help you meet your goals

Our Health Coach will:

  • Review your current health concerns
  • Work with you to provide guidance and tools for healthier living, such as keeping a food log, and understanding nutrition labels
  • Using Motivational Interviewing to work with you to develop strategies to help you achieve your health goals
  • Help you quit using tobacco

Our Social Worker will:

  • Connect you with community/financial resources
  • Assist you or a loved one with long-term care planning resources
  • Partner with other agencies to coordinate care
  • Help you set goals to improve your health
  • Provide coaching to help you meet your goals
  • Complete an assessment to identify any other areas for support
  • Help you identify barriers to meeting your health care goals
  • Help you with coping, relaxation and self-care strategies
  • Help you manage symptoms of anxiety and depression

A Registered Dietician will:

  • Review your health assessment and screening results
  • Provide diabetes education
  • Provide nutrition information for specific health conditions

Our Certified Diabetes Educator will:

  • Provide diabetes education

In addition, your Community Health Team can connect you with an exercise program tailored to your needs at a local fitness center. You will work with a personal trainer for two one hour sessions and then receive a free one month membership.

The UVM Medical Center Clinics

Private Practice Clinics

The UVM Medical Center has also rolled the patient-centered medical home model out to the following private practice clinics by providing project management support and, in some cases, helping them through the patient-centered medical home recognition process.

  • Alder Brook Family Health
  • Appletree Bay Primary Care
  • Champlain Center for Natural Medicine
  • Charlotte Family Health
  • Christopher Hebert, MD
  • Community Health Centers of Burlington
  • Essex Pediatrics
  • Evergreen Family Health
  • Eugene Moore, MD
  • Frank Landry, MD
  • Good Health Primary Care
  • Hagan, Rinehart & Connolly
  • Mountain View Natural Medicine
  • Richmond Family Medicine
  • South End Health Center
  • Thomas Chittenden Health Center
  • Timber Lane Pediatrics
  • Timber Lane Pediatrics North
  • Winooski Family Health

If you have questions, please contact the Community Health Team at 802-847-1601.


The UVM Medical Center's Patient-Centered Medical Homes and Community Health Teams are an outgrowth of the Vermont Blueprint for Health, a statewide partnership to move health care to a system focused on preventing illness and complications. After serving as an initial pilot site for Patient-Centered Medical Homes, this model of care has now been expanded to many primary care practices around the state. Download the current Burlington Dashboard to find out what is happening in our Health Service Area.

Medication Assisted Therapy

Our Medication Assisted Therapy clinicians assist patients addicted to opioids with medication and other supports to help them in their recovery.  They connect with patients through their Patient-Center Medical Homes as well as specialty clinics.

To facilitate entrance into treatment please complete the multiparty release form.

The Howard Center Chittenden Clinic Medication Assisted Treatment Program provides outpatient treatment and pharmacotherapy (Methadone or Buprenorphine) to individuals who are opioid dependent.

In an effort to increase access to care for those struggling with opioid dependence, Howard Center, Community Health Centers of Burlington, Maple Leaf Treatment Center, and University of Vermont Medical Center are working together to address this problem.  Please fill out the attached form and send it to one of the above mentioned agencies in order to be listed on our community waitlist. This will allow us to discuss your potential treatment and find the best option for you.

The completed form can be emailed back to MATTreatmentathowardcenter [dot] org (MATTreatment[at]howardcenter[dot]org), or dropped off in person to one of the agencies. You can also mail this back to Howard Center at One South Prospect Street, Burlington, VT 05401.