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Vermont Chronic Care Initiative

Vermont Chronic Care Initiative - Healthy Together


***1/12/2023 - VCCI has a new referral form and this form has been added below.  Please share this new form with your colleagues.  Only VCCI referrals should be sent to the email alias that is provided on the referral form and please note that VCCI is not able to respond to any of these emails. Thank you!

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 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!”

“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.”