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Annual Report on The Vermont Blueprint for Health Summary

Core Content

The Vermont Blueprint for Health is a state-led initiative aimed at improving health and well-being through community-driven strategies. It emphasizes whole-person care, evidence-based practices, and cost-effective delivery of health services. The program has evolved from its initial focus on chronic care management to addressing social determinants of health, prevention, and systemic care coordination.

Main Focus Areas in 2018

The 2018 report highlights three key focus areas:

1. Collaboration with OneCare Vermont

   • The Blueprint and OneCare Vermont work together under the All-Payer ACO Model Agreement, which shifts responsibility and risk for population health to integrated care networks.
   • The Blueprint's Patient-Centered Medical Homes (PCMHs) are a key component of this collaboration, contributing to better savings and quality outcomes in ACOs.
   • The two organizations avoid duplication and instead leverage each other's networks for effectiveness.

2. Strengthening the Transformation Network

   • The Blueprint's Transformation Network includes Program Managers, Quality Improvement Facilitators, and Community Health Team Leaders.
   • In 2018, the state team focused on hiring, training, and supporting these roles due to high turnover.
   • Training included individual coaching, group sessions, and alignment with AHS and OneCare priorities.

3. Innovation in Health Care Delivery

   • The Blueprint continues to act as an innovation engine, developing new models that address complex health and social needs.
   • In 2018, two new initiatives were launched:
     • SBINS (Screening, Brief Intervention, and Navigation to Services): A universal screening and navigation model for mental health, suicidality, substance use disorder, and social determinants of health.
     • Pain Management Pilot Programs: Local systems of care for chronic pain, avoiding high-risk treatments like opioids, with interdisciplinary teams and diverse treatment modalities.

Key Programs and Their Outcomes

• Patient-Centered Medical Homes (PCMHs):

  • Nearly all of Vermont’s primary care practices (137 of 149) participate in the Blueprint.
  • PCMHs focus on team-based care, care coordination, and quality improvement.
  • They demonstrate slower growth in health care costs compared to non-Blueprint practices.
  • The program includes performance-based payments to support quality care.

• Community Health Teams (CHTs):

  • CHTs provide supplementary care to PCMHs, focusing on patient and population health management.
  • They link patients with social and economic services to support healthy living.
  • CHTs are funded by Medicaid, Medicare, and commercial insurers, and offer barrier-free services.
  • In 2018, CHTs implemented OneCare's care model, focusing on chronic disease management and avoiding costly hospital care.

• Women's Health Initiative:

  • Offers enhanced health and psychosocial screening, family planning counseling, and access to LARC.
  • Supports preventive care, mental health, and substance use disorder.
  • Currently funded by Medicaid only, with services available to commercial insurance members as well.
  • In 2018, the initiative added three new women's health specialty practices and four new PCMHs.

• Hub & Spoke:

  • Expands medication-assisted treatment (MAT) capacity for opioid use disorder.
  • Adds new MAT prescribers in Spokes, enhancing local treatment access.

• Self-Management Programs:

  • Includes workplace-based Chronic Disease Self-Management Program and CDC Diabetes Self-Management Program.
  • New offerings planned for 2019 include youth tobacco cessation and youth mental health programs, as well as online delivery of the CDC's Diabetes Prevention Program.

• Data Collection and Analytics:

  • The Blueprint expanded its data scope to include the entire population of insured Vermonters.
  • This allows for better understanding of regional and sub-population health trends.
  • The Vermont Clinical Registry is being enhanced to include clinical outcomes and social determinants of health data.

• Support and Services at Home (SASH):

  • Aims to slow Medicare cost growth for certain participants.
  • Pilots home-based diabetes and mental health care models.

• Vermont Chronic Care Initiative (VCCI):

  • Shifted to include not only the sickest Medicaid beneficiaries but also those at rising risk of health issues.
  • Aligns with Blueprint and OneCare Vermont’s goals for preventive care and community-based interventions.

Quantitative Evaluation Findings

• Health Care Expenditures:

  • Annual growth in person-level expenditures for the full population was 3.01% (2011–2017), while for Blueprint PCMH patients, it was 2.39%.
  • PCMH patients showed lower inpatient expenditures and slower pharmacy cost growth.

• Chronic Conditions:

  • Annual growth rates for COPD, diabetes, and hypertension are all under 2%.
  • The prevalence of these conditions is expected to stay within target limits for 2022 for diabetes and COPD, but not for hypertension.
  • PCMH patients have higher prevalence but slower growth in these conditions.

• Care Settings:

  • There is a shift from inpatient to outpatient care.
  • Care coordination for individuals with mental health or substance use disorders is underdeveloped.
  • SBINS is being developed to address these gaps with universal screening and navigation to services.

• Access to Care:

  • 90.4% of Vermonters with any health care claim visited a primary care provider within the past two years.
  • 88% of adult Vermonters reported having a personal health care provider, indicating alignment between survey and claims data.

Conclusion

The Vermont Blueprint for Health continues to be a central component of the state's health care reform strategy, emphasizing community-led care, shared accountability, and systemic improvements. The program's innovative approaches and comprehensive data analysis support the state's goals of cost containment, quality improvement, and population health. The 2018 report highlights successful collaboration, network strengthening, and new innovations that are poised for broader implementation in the future.