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Care Management

Aligning goals, providing education, & managing care outcomes

Utilizing a patient-centered, strengths-based approach, NVRH Care Managers align patient and clinical goals, provide patient education, and manage financial and quality care outcomes in the hospital. The Care Management Department, which is a multi-disciplinary team made up of nurses and social workers, works collaboratively with the patient, their family, provider(s), hospital staff, and community-based supports to plan, coordinate, evaluate, and implement the options and services required to meet the patient’s health needs. The department also utilizes available resources to promote quality, cost-effective outcomes for the timely discharge of a patient.

NVRH Care Management services are available to all patients: daily assessment is provided to inpatients and medical social work services are provided to patients of all ages in the Emergency Department, Medical-Surgical Department, and Outpatient Services Department. Day Surgery and Birth Center receive services by consult.

Care Management services include: 

  • Advocating for patient goals and perspectives
  • Providing patient and family education
  • Comprehensive psychological, social, spiritual, and financial assessments
  • Community-based services coordination
  • Insurance navigation support
  • Crisis intervention and safety planning
  • Fetal demise decision navigation
  • Complex care coordination (short and long term)
  • Referral processing, prior auth and complex discharge planning
  • Navigation of End-of-Life Care decision-making

Monday – Friday, 8:30 a.m. – 5:00 p.m. Weekend hours vary.


Phone number: 802-748-7531

Northeastern Vermont
Regional Hospital

PO Box 905, 1315 Hospital Drive
St. Johnsbury, Vermont 05819

802-748-8141  |  TTY/TTD, Dial 711

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