Vermont’s Bold Experiment in Community Driven healthcare Reform

Hostetter M, Klein S, McCarthy D
Publication Year: 2018
Patient Need Addressed: Behavioral health, Care Coordination/Management, Chronic Conditions, Substance Use
Population Focus: Complex care, Medicaid beneficiaries
Intervention Type: Partnership
Type of Literature: Grey

OneCare’s vision is to unite the physical health, mental health, and social services sectors in serving patients with the most complex needs, much as the federal Accountable Health Communities initiative seeks to forge clinical and community partnerships to address factors such as unstable housing or social isolation that contribute to poor health. Rather than hiring its own staff to organize this effort, OneCare is relying on care coordinators already in the field as a result of Vermont’s Blueprint for Health. The Blueprint for Health, a statewide initiative, compels public and private payers to support nurses, social workers, community health workers, and others working to help patients manage their chronic conditions, find treatment for addiction and other behavioral health conditions, and connect with social supports.

Insights Results

Approaches to care

  • OneCare does not hire staff care coordinators. Instead, it offers employees at partner organizations the funds and resources required to help patients manage their medical conditions and address their social, financial, and psychological challenges
  • A frequent next step is for the care coordinator to convene a conference, inviting the patient and members of the support team identified on their ecomap. During the conferences, participants delineate each person’s role in supporting the patient, highlight any gaps in services or duplicative activity, and choose a lead care coordinator (if indicated), who then works with the patient to create a shared care plan
  • OneCare receives additional funding from payers to support care coordination activities and distributes it to Accountable Care Organization (ACO) participants in a way designed to promote shared responsibility
    Care/quality outcomes
  • Medicaid beneficiaries attributed to the ACO are making greater use of primary care and behavioral health services, as well as pharmacy benefits, compared with other beneficiaries. Over the first nine months of the contract, for example, the percent age of beneficiaries with early to late-stage disease who lacked a primary care visit fell to 2% from 4%. Those who were deemed to be at high or rising risk (levels 3 and 4) also had substantially fewer emergency department visits during the first nine months of 2017 compared with similar periods in the prior two years, and fewer hospitalizations compared with the prior year (Exhibits 3 and 4)
    Future considerations
  • More extensive institutional reforms may be harder to accomplish, yet it may be that changes in provider behavior will lead to the greatest cost savings
  • Studying the impact of myriad approaches will be critical to winning support for the care-coordination approach. Without evidence of impact, employers may be reluctant to sign on to the all-payer model
  • Assessing comparative performance, however, may not be easy, given the variation both in the population of health service areas (HSAs) and in their problem-solving techniques. Many rely on different staffing configurations — for example, some depend on credentialed care coordinators, while others use lay workers