Health Services

# of Chronic Care Patients

1,007Jun 2022

Line Bar
Story Behind the Curve

This performance measure reports the number of current patients who are under chronic care.  Chronic care is medical care that addresses pre-existing or long-term illness. 

Chronic diseases and other special needs include but are not limited to asthma, diabetes, HIV, hyperlipidemia, hypertension, mood disorders, psychotic disorders, and substance use disorders. Patients with chronic disease, other significant health conditions and disabilities receive ongoing multidisciplinary care aligned with evidence-based standards and clinical guidelines. These patients are managed through chronic care clinical pathways to ensure comprehensive care, timely follow up and symptom management.

The top five chronic diseases for the VT in-state corrections population are:

  1. Opioid Use Disorder (OUD)
  2. Gastrointestinal 
  3. Respiratory
  4. Musculoskeletal
  5. Hypertension

These reflect the top 5 medical chronic diseases only. Although not among the top 5, Hepatitis C is also among the most prevalent chronic illnesses.

The average number of chronic care patients for FY22 (July 2021-June 2022) was 989 (low: 963, high: 1,007), which was similar to the FY21 average. 


The DOC partners with a Health Services Contractor to perform the work indicated on this performance measure. Currently, the health services data are provided through the Electronic Health Record (EHR) Correctek. 

The DOC has a partnership with the University of Vermont (UVM) regarding the development of the DOC Hepatitis C Virus screening/assessment protocol, which mirrors the VT community standard of care.

Additionally, the Vermont Chronic Care Initiative (VCCI) provides care coordination at release for Hepatitis C Virus patients who are released from incarceration at a VT correctional facility. In June 2021, the DOC's collaboration with VCCI expanded to include VCCI care coordination post release for anyone released from a facility who met VCCI program criteria and elected to participate.

What Works
Action Plan
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy