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

Vermont Chronic Care Initiative (VCCI)

% of members ages 18+ enrolled in Medicaid during the month who are screened by VCCI within 2 months

0.0%Jun 2020

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Notes on Methodology

  • New to Medicaid (NTM) members
  • MMIS/Data Unit
  • Vermont Health Connect (VHC)
Story Behind the Curve

In effort to align with healthcare reform efforts and the system of care, the VCCI will be outreaching members new to Medicaid, screening for access to primary care, health conditions and social determinants of health.  The goals are to 1) orient the member to the system of care to including navigation of services to health-related needs such as housing, food security and 2) onboarding members ahead of their anticipated future, ACO attribution to include facilitation of access to primary and dental care, and as needed, connection to community supports and resources.

In response to COVID-19, VCCI suspended outreach to those new to our health plan with consideration of the following:

  1. VCCI Staff- 5 redeployed to VDH weekend of March 14th with VDH work beginning March 16th; significant reduction in the number of VCCI full time staff due to school closures or care for family, resulting in 8 staff needing to teach/care for children at home, while maintaining case management of complex members on their caseload; two vacancies.
  2. Health care and dental clinics were limiting in person visits +/or closed which would have presented as barrier to facilitating direct member connection with provider of their choice.  

This suspension gave us opportunity to focus on high risk groups during pandemic and our outreach coordinators helped to support outreach of these complex members.

We resumed outreach to those New to Medicaid in June, and have done outreach to all members new to the plan as of March, 2020 to present.


As we begin to look back on our decision to suspend our new to Medicaid outreach, we feel prepared to approach this differently if this decision needed to be made in the future.


Some constant influences on measure outcomes:


Members without valid phone numbers due to disconnected services; phones without voice messaging set up.


Members not returning phone calls; nor responding to mailed screenings.


Members declining to engage in screening.

Last updated:  10/15/2020

  • Ongoing training/coaching of VCCI team to inform system of care issues such as PCP establishment, connection to local community resources (community action, self-management programs, transportation options).
  • Provide regular training to staff to ensure documentation is standard in order to capture data.
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