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Vermont Chronic Care Initiative

Vermont Chronic Care Initiative - Healthy Together

 2023 AHS Team Beacon Award     

For resources available to people that have been impacted by the recent flooding, information can be found on the following website:  Flood Resources |

The email address on the VCCI referral form is to be used only for sending referrals to VCCI because VCCI is unable to respond to any incoming emails sent to this email address:  

Camden Coalition and AHS Vermont Chronic Care Initiative

Camden Coalition and AHS Vermont Chronic Care Initiative

The Vermont Chronic Care Initiative (VCCI) provides holistic, intensive, and short-term case management services to Vermont residents enrolled in Medicaid, including dually eligible members. VCCI works with members  referred for complex case management by healthcare and human services providers, state colleagues and partners, as well as through our care management predictive modeling methodology. VCCI case managers and outreach coordinators are also welcoming members new to Medicaid (NTM), and screening members to identify and prioritize needs. Our screening tool asks members questions about access to care (including primary and dental), the presence and status of health conditions, and inquiry about other needs that would assist them in maintaining and/or improving their health such as as housing, food and safety. The VCCI team works to connect members with medical homes, community-based self-management programs, local care management teams and help members to navigate the system of health and health related care.

The VCCI utilizes common tools and processes adopted by the local community care teams as part of the complex care model to include eco mapping, identification of lead care coordinator, facilitating care teams, and shared care plan development.

Licensed case managers trained in the complex care model, deliver services in communities throughout the state.

Customers Feedback:

"... my care team was great! I have rarely seen such caring kindness and most of all support provided... continue to work with tools given to me - they work!"

"An Updated A1c - started at 12 is now 5.6... I couldn't have done any of this without you.  Thank you for helping me start getting my life back!"

"My VCCI Case Manager was “exceptionally helpful in my own goals of getting my overall health to a better place, both mentally and physically.  When we began working together, I didn’t have a PCP, dentist, or counseling services.  Now, I do have those services thanks to the help of this program and can happily say that my scores for both depression and anxiety have decreased throughout this time with VCCI.  I appreciate the services received so very much and would absolutely recommend this program to others in need of some extra help!”

“Being a VCCI participant saved my life.  My Case Manager guided me to success during a very difficult time in my life when I was facing so many challenges and truly got to know me and my health conditions.  Lou made sure my medicine management was on track while being homeless.  It was helpful to have coordination of care with Economic Services and doctors.  Lou helped me get home to my support system and providers in Chittenden County when we were told it wasn't possible.  Your program is absolutely amazing, and I am beyond grateful I was referred.  Because of your initiative, I am now stable, have a place to call home and can continue on a good path."