Total Program Budget FY 2017: $2,608,703.46

The Vermont Chronic Care Initiative (VCCI) identifies and assists Medicaid beneficiaries with chronic health conditions and /or high utilization of medical services to access clinically appropriate health care information and services. DVHA care coordinators are fully integrated core members of existing Community Health Teams and are co-located in provider practices and medical facilities in several communities. The population are the top 5% utilizers of the healthcare system, accounting for 39% of healthcare costs.

VCCI is focused on utilization measures with documented reductions in all areas, including for ambulatory care sensitive (ACS) inpatient hospital admissions, readmissions and emergency department use. Staff are embedded in multiple high-volume hospital and primary care practice sites to support care transitions as well as direct referrals for high risk/cost members. The VCCI continues to receive national recognition for its model and results including by CMS and the National Academy for State Health Policy (NASHP).

VCCI will continue to be an integral component of healthcare reform efforts given the initiative’s focus on holistic case management and the required expertise in human services necessary for successful case management and care coordination of a high complexity population, including those with significant social needs. The Unit has taken a leadership role in the enterprise level MMIS/Care Management system procurement process, with an anticipated go live date of early SFY 2016. VCCI has developed collaborative relationships with contracted Medicaid ACO partners and will continue strategic efforts to leverage limited resources toward common goals. Inherent in this, VCCI is active on the payment reform Care Management and Care Models (CMCM) workgroup and has a leadership role in the care management learning collaborative planning and implementation to assure service integration.