Population Health Initiatives

We care for our community with a team-based approach, nurturing relationships to achieve patient centered, cost effective, and high-quality health care.


NMC’s population health team is focusing on:

  • Improving health equity
  • Advancing preventative screenings
  • Increasing annual wellness visits
  • Reducing hospital readmissions
  • Increasing access to health workshops

Health Equity

Equitable access to care means you are receiving the right care, in the right place, at the right time no matter who you are or what your care needs are. 

  • Hired consultants to assess NMC’s needs for better serving out patients and staff with equity. 
  • Better utilize data to understand who we treat and their experiences and outcomes to improve how we serve folks of every identity and background.
  • Better understand the whole person to find strategies that care for the whole person 

Annual Wellness Visits (AWV)

Medicare offers FREE Preventative Annual Wellness Visits for people over the age of 65. This yearly appointment with your provider focuses on preventing illness & disease, while assessing your health risks. Your AWV is mostly a simple conversation with a qualified healthcare professional. It’s your chance to discuss your personal health goals, plan for prevention, and identify risks.

Learn more »


Health Workshops

We partner with My Healthy VT to offer ongoing health workshops to support individuals manage their chronic conditions, including hypertension, diabetes, tobacco usage, and chronic pain. These programs are offered in-person and online. We are always looking for community partners to serve as hosts, and we are also looking for folks to serve as facilitators – training and resources are offered to qualified individuals.

Please reach out to Nichole Cunningham for more information »

Preventative Screenings

NMC is actively working with our partners and throughout our community to decrease the impact of cancer through:

  • Prevention
  • Early detection/early treatment
  • Support and care for our community members

Connect with your Primary Care Physician to understand what screenings you need as your first step.

Learn more »


Transitions of Care

Being readmitted to the hospital after discharge is not beneficial for anyone, least of all our friends, neighbors, and family members. The Population Health Team is working collaboratively with the hospital, area agencies, and primary care providers and their care teams to ensure health care transitions are safe, effective, and reduce any gaps in service delivery and cross agency communications. We do this by leveraging relationships, supporting the care teams with communication strategies, and by identifying any quality improvement opportunities at the Health Service Area level that can improve transitions. 


Our Work in the Community


Cancer Committee: NMC has an active cancer committee focused on prevention, early detection, and survivorship. 

Community Health Needs Assessment: Every three years the hospital conducts a community health needs assessment. Learn more »

Community Health Team: NMC is the administrative entity and coordinator of the Blueprint expanded Community Health Team and Medical Assisted Treatment for opioid use disorder team in our Health Service Area. Learn more »

Franklin Grand Isle Tobacco Prevention Coalition: We coordinate the Franklin Grand Isle tobacco coalition that supports tobacco and nicotine prevention and cessation. Learn more »

Jim Bashaw Fund: Northwestern Medical Center administers the Jim Bashaw Fund that supports families and individuals experiencing catastrophic events and cancer diagnosis. Learn more »

MyHealthyVT: Free health workshops offered through the VT Dept of Health. Learn more »


Statewide Partners


The Vermont District Office of Local Health Saint Albans is an instrumental partner in setting and implementing public health strategies to address population health outcomes that impact individuals in our community. We work closely on aligning joint initiatives. Learn more »

We partner with one of Vermont’s accountable care organizations, OneCare Vermont to address region-wide clinical quality outcomes to improve health in our community. Learn more »

The Vermont Blueprint for Health is a statewide program focused on supporting the delivery of high-quality care to Vermonters by investing resources in the Patient Centered Medical Home model, the Medical Home model, and the Pregnancy Intention Initiative. Learn more »