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

Vermont Chronic Care Initiative (VCCI)

% "New to Medicaid" members who accepted help with PCP establishment and who successfully established care with practice/medical home

0.0%SFQ1 2021

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Notes on Methodology

  • Members
  • Healthcare practices
  • Blueprint Community Health Teams
  • Medicaid Member Services
  • Bi-State
Story Behind the Curve

In an effort to align with healthcare reform efforts and the system of care, the VCCI is outreaching members new to Medicaid, screening for access to primary care, health conditions and social determinants of health.  One of the goals of this effort is to onboard members ahead of their anticipated future ACO attribution to include facilitation of access to primary care. Our new to Medicaid screening begins with asking each member if they have established primary care. If member answers ‘no’, they are then asked if they would accept help in facilitating primary care. VCCI staff then offer a 3-way phone call to actively connect member to primary care office/medical home; provide number to Medicaid Member Services to update primary care provider.

In response to COVID-19, our outreach to those new to Medicaid was suspended March-May 2020, and so we expected this measure would also be impacted.

Some influences on measure outcomes include:

Primary care offices continue to decline to schedule a new patient appointment, without receipt of medical records from previous provider. 

Members preferring to independently call provider practice to establish care versus accepting VCCI offer of 3-way phone call, and perhaps not following through on own.


Despite coaching on importance of primary care, members may still decline offer of primary care contact options; decline 3-way phone call to provider practices.

Primary care offices not accepting any new patients.

Members not able to be outreached by phone, are mailed new to Medicaid screening; and may not return the screening. Note - Business reply envelopes are included with screening.


VCCI staff not updating plan of care with reflection of issue of lack of primary care resolved and therefore, data cannot be pulled for reporting purposes. Staff have shared that they are waiting to resolve this issue until member has attended appointment versus resolving when providing an appointment date as they feel that an appointment scheduled is separate than attending the appointment. Our eQ care management system will be amended to have an additional goal added to our primary care issue, so that staff can resolve PCP appointment scheduling as a separate issue from PCP appointment attendance.


Last updated:  10/15/2020

  • Work and communication with BP, OCV and community health teams with updates on PCP access/barriers and cooperative brainstorming on realistic approaches to address these barriers.
  • VCCI staff to continue to utilize motivational interviewing skills when coaching to importance of primary care and facilitation to primary care home of member preference, with goal of primary care appointment establishment.
  • All members outreached are mailed a follow up letter with information on their primary care provider option (contact information; appointment date, etc.); if member declined VCCI intervention, letter includes information on primary care options; and also includes Medicaid Member Services contact information.
  • Continued training on utilization of care management system plan of care to capture successful establishment of primary care with members.
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy