Vermont Chronic Care Initiative (VCCI)

What We Do

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 +/or improving their health such 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 assist in navigating the system of health and health related care.

Who We Serve

VCCI serves Medicaid members except members:

  • receiving CMS funded case management
  • receiving services through Department of Aging & Independent Living (DAIL) or Department of Mental Health (DMH) 
How We Impact

The VCCI case managers are community based; and are stationed within the communities they live in. They work closely with their community health care and social service providers; collaboratively working with each other and the member on the member identified priorities. The case managers are closely linked with their AHS Field Directors – which has proven vital when working with members that may be involved with DCF, DOC, DMH, DAIL, and VDH. VCCI case managers meet with members in varied locations- homes, PCP offices, homeless camps, hospitals, shelters- successfully engaging members that have been historically hard to find and difficult to engage.

Action Plan


  • Align with health care reform efforts and formal adoption of complex care model and team-based care; utilization of common tools.
  • Facilitate connection to appropriate level of care within the ACO model either at primary care or with a care team.
  • New to Medicaid or those members with gaps in PCP care – outreach/screen – orient to system of care; provide brief intervention to facilitate PCP and dental access.  Connect to appropriate level of care.
  • High/Very High Risk – short term case management to connect to appropriate level of care. 
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy