Provides holistic care services to all community members that may include the following: Nursing, Behavioral Health and Physical Health Coaching services: Nutrition education, exercise education and counseling, short-term behavioral counseling, Diabetes education, individual health coaching, medication management, weight management-individual and group support, smoking cessation, Advanced Directives, Fall Safety assessments, medical transportation and dental solutions. Community Connections Community Health Team also provides Resource Advocates who will assist with completing applications for the following services and assistance: health insurance (VT Health Connect and Medicare and Medicare D comparisons), SSDI/SSI, and prescription costs, as well as application assistance for housing, food, and utilities. The team also includes VT Health Connect navigators and assistors, as well as care managers for individuals who require support maintaining independence and stability within the community. Provides support services for patients and their families during hospitalization and upon discharge, for people receiving outpatient services, for previous patients and for other people not previously associated with the facility who need the service. Implements a Community Health Improvement Program based on the Community Needs Health Assessment.