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Vermont Chronic Care Initiative (VCCI)

last modified 01/10/2018 - 04:27 PM

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**Make a referral to the VCCI**(links to form) - Complete the referral form and fax to 802-288-1417


 Call us toll free at 1-866-900-5004



The Vermont Chronic Care Initiative (VCCI) is a legislatively supported Medicaid health care reform strategy. Enacted in 2007 and with statewide VCCI coverage by 2008 the VCCI targets Medicaid members at risk for adverse health outcomes for short term, holistic, intensive case management and social support services required to improve individual and population health and related health care costs. Members are identified using claims history, supplemented by risk stratification. The VCCI is offered through Vermont Medicaid/The Department of Vermont Health Access.



VCCI case managers meet with members in their homes or our offices to work on self-management plans and attend provider appointments to help facilitate collaborative care planning and meeting clinical gaps in care.



Goals of the VCCI program include:

•    Improve access to and utilization of primary care (Medical Homes)
•    Improve member adherence to medical treatment
•    Engaging and empowering members to participate in self-management of their health 
•    Reducing emergency and inpatient hospital utilization for ambulatory care sensitive conditions

 In SFY 2014, the Vermont Chronic Care Initiative demonstrated a number of successes, including:
•    Net savings to Vermont Medicaid equaling $30.5 million over anticipated costs
•    15% decrease in unnecessary emergency room utilization 
•    30% decrease in inpatient hospital stays
•    31% decrease in 30-day hospital readmissio


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Services are provided to non-dually-eligible Medicaid members who do not have CMS funded case management. For more information about VCCI eligibility, see Eligibility. If you are interested in making a referral to the VCCI, complete the Referral Form and fax to the number provided on the form.



“MOMS”-Medicaid Obstetrical and Maternal Support Service

 In 2015 the VCCI began to offer case management for at-risk pregnant women, with focus on those with a history of premature delivery, mental health diagnoses, or substance use during pregnancy. 


        o   MOMS Service Provider Referral Brochure-Information for providers referring patients to the MOMS Service.

                 o   MOMS Service Client Brochure- Information for patients who have been referred to the MOMS Service.

                 o   Referral Form-Make a referral to VCCI or the MOMS Service!


Quick Links

 VCCI Action Plans VCCI Contact Information
CMS VCCI Case Study (p. 33-37) 
VCCI Named Outstanding Program 
 VCCI Annual Reports       
 Continuum of Health ServicesBlueprint and VCCI Integration