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

Vermont Chronic Care Initiative (VCCI)

% of VCCI enrolled members with a face to face visit during the month

96.0%Sep 2020

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  • Medicaid Beneficiaries
  • 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

One of the hallmarks of the Vermont Chronic Care (VCCI) is the provision of services through in person meetings with members, to include in their homes, at shelters, motels, and homeless camps.  This mode of engagement with member provides the opportunity for an assessment of one’s environment and culture and often supports the evolution of a trusting relationship- all to support effective self-management and sustainable change.  This measure is calculated as the percent of all members enrolled during the reporting month that received at least one face to face visit.

In response to COVID-19, the VCCI suspended any in person visits, (member and health/human services providers), March 13, 2020 and expected to see the drop in this measure. Our VCCI team continued to provide services and engage with members through technology – telephone, SKYPE, face time. The VCCI has developed guidance for resumption of in person visits, working with DVHA CMO and other AHS partners.  This plan has been shared with our full VCCI team and resumption is planned for week of October 19th

The VCCI continues to work on staffing goals and standardized documentation and reporting in the new MMIS/Care Management system. Always present influences to this measure are that 1) This measure is based on the month activity and only includes Face-to-Face visits with members that were enrolled during the entire month in the calculation as well as excluding members in an "on-hold" status. This is impacted by members lost to contact. 2) This may also be impacted by the New to Medicaid focus which is done telephonically.

Staffing resources impact this number as currently we have two RN case mangers here less than 6 months and one staff member vacancy.

Last updated:  10/15/2020

What Works

Face to face visits offer an opportunity for further member assessment and establishing meaningful relationship/engagement and trust required for health coaching/education on behavioral changes required for improved health. Home visits support assessment of the home environment, precipitating factors in their health/chronic health conditions (i.e. mold exposure for asthmatics with recurrent ED usage) and also offer the chance to perform medication reconciliation and assess adherence to pharmacy treatment. The literature does support the effectiveness of face to face case management vs. telephonic as regards results and sustainable change.

  • A few staff are over booking daily visits with the experiential knowledge that some members may cancel the visits during the week.
  • Other staff offer members consistent time/day of visits; before leaving a visit, staff are scheduling the next follow up visit.
  • Provide information to member that face to face visits are expected part of their participation in the VCCI program.
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy