Medicaid's Vermont Chronic Care Initiative (VCCI) and 1 more...less...

Vermont Chronic Care Initiative (VCCI)

# new VCCI eligible members enrolled in care management

73Sep 2020

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  • Community Health Teams
  • Healthcare Providers
  • Community Service Providers
  • State Partners to include AHS Field Directors, DCF, DOC
  • DVHA Colleagues to include QIU, Pharmacy, COU
  • Chief Medical officer; DVHA
  • MMIS & Care Management vendors
Story Behind the Curve

The VCCI continues to provide case management services to at risk/high risk members identified through health and human services providers, state colleagues and partners, as well as through our care management system predictive modeling methodology.  Reasons for referring to VCCI remain as 1) community/home-based in person visits needed for complex members 2) case management services provided at intensity that is needed, and not available and 3) VCCI skilled at both health and health related navigation. VCCI also welcomes 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 (housing, food, safety).


This measure captures new enrollments/month only – it does not reflect the total VCCI caseload. Recent drop in this measure, starting in April 2020, is notably due to COVID-19 and how our health and human services sectors needed to limit or cease in person office visits for public health and safety reasons, and so less patient pool to refer to VCCI.  Beginning in June the number of enrollments has steadily increased as our health and human services sectors and Medical and community providers have opened as the State enters Phase 3 of the pandemic. This re-opening has helped increase referrals and opportunities to partner with referral sources again.  During this time, 4 VCCI RNs redeployed to VDH x1 month, and 2 remain redeployed through middle of June; one of our Outreach Support Coordinators was redeployed x2 weeks to VDOL. In June, our full team had resumed core job duties with VCCI and our state continued to gradually open services, and so we anticipate the number of referrals to begin to increase, thereby increasing the # enrolled into VCCI.

Common factors that may impact this measure more consistently are 1) staffing levels as VCCI currently has two RN case managers that are here less than 6 months; and 1 RN position that is currently frozen and 2) as staff build and reach caseload capacity, there may not be the bandwidth to enroll new members each month.

Last updated:  10/15/2020

  • Continue to focus on increasing enrollments to achieve caseload expectations.
  • Collaborate with local care teams and Providers to help identify at risk VCCI eligible members for enrollment
  • Provide access to census lists to Outreach and support coordinators for identification and outreach at time of discharge to members who have had a recent ED visit. One of our nurse case managers will be assigned to review the inpatient census lists to identify and outreach VCCI appropriate members.
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy