Community nurse programs are getting a lot of airtime this election. Here’s how they work.

Jodi Hoyt’s office is a nurse’s bag and an accordion file folder in a rainbow of colors.

She totes those items from house to house while checking on patients in her role as the community nurse for the towns of Chelsea and Tunbridge. 

It’s a role that’s gotten a fair amount of airtime recently as the Democratic/Progressive candidate for governor, Amanda Janoo, touts the virtue of community nurses and cites their work as a model for the type of publicly funded primary care she hopes to bring to Vermont.

In Vermont Public’s Oct. 21 debate, where Janoo and Republican Gov. Phil Scott pitched their competing visions for healthcare reform, Janoo specifically cited Hoyt’s job.

“In Tunbridge, for example,” Janoo said, “their community nurse is just a municipal employee, and that ensures that everybody has some sort of local healthcare. And I love that model, right?” she said. 

The shoutout came as a surprise. “Oh, I had no idea!” Hoyt said the next morning, smiling as she read a text from a friend letting her know about it.

Mostly she keeps her head down and focuses on the work. “I help everyone,” she said. “I’m trying to reach the demographic that doesn’t see a doctor regularly, whether that’s college students or the elderly, for whatever it may be.”

Hoyt said she started the program in Tunbridge in 2022 after refining her pitch to the town more than once. She’s since grown it to 12 hours a week, from the original five to eight hours. A year ago she expanded to Chelsea, where she grew up, and now works 10 hours a week there as well. 

Spending a college semester in Botswana first exposed Hoyt, then a young nursing student, to the idea of community nurses — a caretaker who is deeply embedded in the community. She loved the concept, which has now become her reality, that a nurse might be flagged down at the market or a soccer match to look at someone’s rash or address a concern about an elderly neighbor.

Coincidentally, the idea was already taking root around the same time in Vermont’s Upper Valley, where Hoyt grew up. Community Nurse Connection began as a project in 2010. The nonprofit network has evolved to now include 12 community nurse programs in Vermont and five in New Hampshire. 

Each community approaches the role a bit differently, said Kristin Barnum, the executive director of Community Nurse Connection. Some towns, such as Tunbridge, fund the position as a municipal employee, while others create a nonprofit fund. What’s important, Barnum said, is that the nurses’ services are free to patients and not billed to Medicare or any other insurer. 

“A lot of people will say to me, ‘Well, you know, this is such a great idea. Don’t you think it should be billable?’ and my quick answer is no,” Barnum said.

The salary model gives the community flexibility to administer care broadly. A nurse might sit and talk with a patient for half an hour about nutrition or help them sign up for food assistance. The nurse can develop a care plan according to the patient’s own goals, rather than seeing them for a set number of visits in a set number of weeks to meet goals defined by a doctor or insurer.

It also means that anyone can refer a patient to a community nurse, whether that’s another healthcare professional discharging a patient from the hospital, a person worried about their aging parent or someone recognizing a need for help themselves. 

But the funding model also limits the amount of direct care the nurses can give. Because they are not under any physician’s orders, community nurses cannot perform hands-on care the way a home health nurse billing Medicare would.

Katie Williams, Hartford’s community nurse, calls her approach “slow medicine.” 

The ability to tailor the care to patients’ needs over time enables relationships to build, “which allows for trust, which allows for really understanding the patient’s complexity,” Williams said. “What I like to say is (we get) the ecology of their whole health picture.”

On average, Williams spends an hour per visit with each of her patients, who normally number about 45. She supplements that work with daylong drop-in clinics at Hartford’s senior center. 

The town is able to connect with Dartmouth Hitchcock Medical Center to see patients’ records and medication lists and help coordinate ahead of medical appointments, Williams said.

“I like to say that the community nurse role is this hybrid between social care and personal health. The line between those two is so thin and perhaps even invisible,” she said. 

Hoyt sees her role as more directly clinical than a social worker’s. 

“I’m always evaluating. I can’t turn it off,” she said of her tendency to be attuned to symptoms no matter the context.  

Hoyt cites an example. While addressing the patient’s mobility issues in a home visit, Hoyt noticed that the woman’s husband had what looked like a large melanoma on his chest where his shirt was unbuttoned. When Hoyt asked about it, he brushed it off, she said. But with some persuading and his eventual permission, Hoyt sent a picture to a dermatologist friend, who confirmed Hoyt’s concern. He needs to get that removed as soon as possible, Hoyt remembers the friend saying. 

But the husband didn’t have a doctor to make the needed referral. So Hoyt helped him fill out the paperwork to establish a relationship with a primary care provider. The couple had no internet at their house, so when it was time for the husband’s virtual care visit, Hoyt set up her phone for him to take the call. She walked him through each step to eventually get the melanoma removed.

“I don’t think anyone else would have caught it,” she said. It was only because she was in the home and able to shift her responsibilities beyond the one patient that she was able to help, she said.

Catching cancers early can avert much more costly care later. Reducing the need for hospital care and 911 calls is one of the community nurse program’s biggest selling points.

“Many of these clients, especially if they live alone, if they fall, they call 911, even if there’s no physical injuries,” Barnum said. Medicare doesn’t reimburse emergency medical services if they do not take a patient to the hospital, so often the patient goes to the emergency room. Barnum said community nurses have averted those kinds of calls by removing fall risks — such as installing handrails or ramps. 

In Hartford, Williams’ job is housed within the fire department. The department connects her with residents who have had multiple nonreimbursed falls — usually people who are not taken to the hospital. The department also turns to Williams when staff respond to a call and see red flags in the home, such as a lack of heat or signs of dementia. 

Older patients sometimes call 911 because they’re lonely and scared, Barnum added. But knowing a visit with the nurse is on the calendar can lower their anxiety and avert calls. 

In Tunbridge, Town Clerk Bonnie McCrillis sees Hoyt’s role as invaluable. 

“To be honest with you, just here in Tunbridge, Jodi could be kept busy eight hours, 10 hours a day, six, seven days a week,” McCrillis said. “If she could clone herself three times, I think she would have a good start on being able to service the people like she would like to.”

Community Nurse Connection tracks outcomes across its programs each year and has found that the biggest impacts are in reducing falls, helping elderly people continue living independently at home and alleviating anxiety and isolation. 

Outcome metrics are not why Hoyt is in the game, though. 

“Most of the time, it’s not that life-saving,” she said of the care she provides. “I don’t think people realize the small things, all the little things are also life changing.” 

The work clearly invigorates Hoyt, who radiates spunky energy in her pink scrubs. She said she feels like she’s only just getting started. 

“I would like to see a community nurse in every town,” she said. “I want to keep my program successful, and I want to keep going.”

Read the story on VTDigger here: Community nurse programs are getting a lot of airtime this election. Here’s how they work..