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Vermont Chronic Care Initiative (VCCI)
last modified
09/02/2009 - 09:30 AM
Mission
· Identify and assist Medicaid beneficiaries with chronic health conditions access clinically appropriate health care information and services
· Coordinate the efficient delivery of health care to this population by attempting to remove barriers, bridge gaps, and avoid duplication of services, and
· Educate, encourage and empower this population to eventually self-manage their chronic conditions.
Goal
The Vermont Chronic Care Initiative (VCCI) strives to improve the health of Medicaid beneficiaries by addressing the increasing prevalence of chronic illness. The VCCI emphasizes planned, integrated and collaborative care for beneficiaries who exhibit
- high-prevalence chronic disease states
- high-expense utilization
- high medication utilization and/or
- high emergency room and inpatient utilization.
The VCCI supports patient self-care, appropriate utilization of evidence-based health care services, and efficient coordination among providers, hospitals, community resources and state agencies. It is a holistic approach that considers physical, behavioral and socioeconomic barriers to health improvement, such as challenges with safe and affordable housing, food security, transportation to medical appointments and health literacy. Eligible Medicaid beneficiaries who do not also have Medicare or other insurance are identified through a variety of sources, including medical claims, hospital discharge plans and referrals from healthcare providers.
The VCCI focuses on Medicaid beneficiaries who have one or more of the following chronic health conditions: Arthritis, Asthma, Chronic Obstructive Pulmonary Disease (COPD), Chronic Renal Failure, Congestive Heart Failure (CHF), Depression, Diabetes, Hyperlipidemia, Hypertension, Ischemic Heart Disease, and Low Back Pain.
Method
The VCCI is a tiered approach with intervention services along a continuum from printed education and self-management information for lower risk beneficiaries, to telephonic disease management services for those at moderate risk, to intensive face-to-face case management to coordinate medical and social services for the most costly and medically complex beneficiaries. Beneficiaries move seamlessly between service tiers as their needs change.
VCCI RN care coordinators, RN health coaches, and medical social workers are assigned to eight districts to provide statewide services. Teams and regions are shown on the map.
VCCI staff work with beneficiaries and their primary care providers (PCP) using evidence-based clinical guidelines and tools to develop customized care management plans and goals. Health education, referral, coaching and support services may include
· Facilitating access to a medical home, developing a holistic care plan, and coordinating appointments and medical services among a variety of providers, including mental health and substance abuse resources
· Facilitating transportation to medical appointments to encourage proactive care and reduce the number of missed appointments
· Facilitating referrals to community and social support services for assistance with needs such as purchasing prescription medications or food, locating safe and affordable housing, or seeking employment.
PCP Information
The VCCI provides outreach and support to PCPs and facilitates communication between beneficiaries and their PCP. VCCI notifies PCPs when their patients decide to participate in the VCCI, cannot be reached or decline services. Care coordinators who provide face-to-face case management emphasize PCP involvement and provide periodic updates on patients’ progress. In addition, PCPs receive enhanced payment for each of their patients enrolled in case management.
