The Vermont Chronic Care Initiative (VCCI) provides holistic, intensive and short-term case management services to Vermont’s most vulnerable members. VCCI works with health care providers to identify members with complex needs who would benefit from care management services. In addition to the traditional claims-based methodology, focused on our high cost/high risk population, health care providers and community partners may send over needs-based referrals on non-ACO attributed individuals whom, using their clinical judgment, need complex care management. Referrals on dually insured (those with Medicaid insurance in addition to another federal and/or commercial insurance) members are now accepted. VCCI case managers are also welcoming new members to Medicaid, by outreaching and asking questions about primary care provider, health conditions and other supports that would assist them in maintaining or improving their health as well as housing, food and safety. The VCCI team works to connect members with medical homes, community-based self- management programs, and local care management teams.
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.
“She helped me change my life from being homeless, pregnant, a small bag of belongings, no primary care or OBGYN & in abusive relationship with no support in the community of family to being a full-time student w/ help from Voc Rehab, 3squares, GA, my PCP, and OBGYN; helped me find housing, leave an abusive relationship. She helped me also find support in the community.”
“My Case Manager helped me with ways to manage my stress. She also helped me find ways to remember to take my medications daily. She was very supportive of me…”