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Medicaid's Vermont Chronic Care Initiative (VCCI) and 1 more... less...

Vermont Chronic Care Initiative (VCCI)

% "New to Medicaid" members who accepted help with PCP establishment and who successfully established care with practice/medical home

Current Value


SFQ2 2022


Line Bar

Notes on Methodology

Story Behind the Curve

This measure is important because connection with primary care facilitates early identification of medical/psychosocial issues, assistance with health maintenance and better communication.

To align with healthcare reform efforts and the system of care, the VCCI is outreaching members new to Medicaid and screening them for access to primary care, health conditions and social determinants of health.  One of the goals of this effort is to onboard members ahead of their anticipated future Accountable Care Organization (ACO) attribution to include facilitation of access to primary care. VCCI staff then offer a 3-way phone call to actively connect member to primary care office/medical home; provide number to Medicaid Member Services to update primary care provider.

Factors that influence this data include that primary care offices that require receipt of former health records before scheduling, long wait times for new patient appointments, and members not showing up for visits.  VCCI continues to work with the Blueprint, the ACO and community health teams with updates on PCP access/barriers and cooperative brainstorming on realistic approaches to address these barriers.

In response to COVID-19, VCCI outreach to those new to Medicaid was suspended from March through May 2020, and so we expected the rate for this measure to be impacted.  In June, VCCI resumed telephonic outreach and started with lists from March.  As of September 2020, VCCI is caught up on these calls.

Narrative last updated:  12/02/2020


  • Members
  • Healthcare practices
  • Blueprint Community Health Teams
  • Medicaid Member Services
  • Bi-State

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Scorecard Container Measure Action Actual Value Target Value Tag S A m/d/yy m/d/yyyy