Vermont Business Magazine OneCare Vermont is one of six organizations nationwide chosen to participate in Transforming Complex Care, a multi-site demonstration aimed at refining and spreading effective care models that address the complex medical and social needs of high-need, high-cost patients. This national initiative, made possible with support from the Robert Wood Johnson Foundation and led by the Center for Health Care Strategies (CHCS), will work with six organizations to enhance existing complex care programs within a diverse range of delivery system, payment, and geographic environments.
Health care policymakers, payers, and providers increasingly recognize the need for integrated care models for patients with complex needs, a population that accounts for disproportionate health care costs. These patients frequently have multiple medical, mental health, and substance use treatment needs, and face social and economic challenges that further complicate their health outcomes.
The RWJF grant, led by the Center for Health Care Strategies, will enable OneCare to expand existing work in four Vermont communities by providing enhanced project management and multidisciplinary team support.
Organizations in the four communities will:
- Work to engage a target number of OCV attributed patients with complex care needs in cross-organization care coordination activities
- Utilize care coordination software to facilitate cross agency communication, identification of a lead care coordinator, as well as the development and continued updates to a shared care plan
- Complete evaluation tools at the specific intervals to determine the intensity, intervention, and outcomes associated with care coordination activities
- Participate in continuous quality improvement activities related to enhancements in care coordination workflows and refinement in the utilization the care coordination software
The benefits of this project will extend across Vermont. Learnings, tools and resources from the work in these communities will be shared with communities statewide. With this support from RWJF, OneCare and the regional collaborative will be better able to coordinate services for high and rising-risk patients and achieve the three aims of health care reform: improve Vermonters’ health, improve Vermonters’ experience of their care and control the cost of care.
“Health care providers and delivery systems across the country are looking to implement complex care models based on emerging best practices,” said Allison Hamblin, MSPH, vice president of strategic planning at CHCS. “Transforming Complex Care will enable leading health organizations to more effectively address the social determinants of health for high-need, high-cost patients, and will offer lessons for replication that maximize existing community strengths.”
OneCare Vermont was competitively selected to participate in the initiative, along with five additional sites intentionally drawn from small- to mid-sized cities. Each site will receive funding support and participate in a learning collaborative offering 1:1 and group technical assistance, peer exchange, and tools. Additional sites and the regions they serve are:
- AccessHealth Spartanburg; Spartanburg County, South Carolina
- Mountain Pacific Quality Health Foundation; State of Montana
- Redwood Community Health Coalition; Northern California
- ThedaCare; Eastern Wisconsin
- VCU Health System; Central Virginia
“Caring for patients with complex needs requires innovative programs that go beyond medical issues to address unmet social needs,” said David Adler, MPA, senior program officer at the Robert Wood Johnson Foundation. “The Transforming Complex Care sites will support a Culture of Health by building the evidence base on improving care for high-need, high-cost patients.”
Over two years, the sites will refine targeted strategies across six key domains for improving complex care, including: (1) care model enhancements; (2) data and analytics; (3) workforce development; (4) financing and accountability; (5) governance and operations; and (6) policy and advocacy. As the program progresses, CHCS will share lessons and tools from the sites’ experiences. Look for more information at www.chcs.org.
About OneCare Vermont
OneCare Vermont is a state-wide Accountable Care Organization (ACO) that works with Medicare, Vermont Medicaid and Commercial Exchange Programs. OneCare Vermont is an extensive network of providers, including most Vermont hospitals, two New Hampshire hospitals, federally qualified health centers, rural health clinics and hundreds of primary, specialty care and Advance Practice Providers. The three part mission of the network is to improve patient care, improve the patient experience of their care and control costs for over 125,000 Vermont beneficiaries.
About the Center for Health Care Strategies
The Center for Health Care Strategies (CHCS) is a nonprofit policy center dedicated to improving the health of low-income Americans, especially for individuals with complex, high-cost needs. CHCS works with state and federal agencies, health plans, providers, and consumer groups to advance innovative and cost-effective models for organizing, financing, and delivering health care services. For more information, visit www.chcs.org.
About the Robert Wood Johnson Foundation
For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working with others to build a national Culture of Health enabling everyone in America to live longer, healthier lives. For more information, visit www.rwjf.org.
Source: Colchester, Vermont, July 6, 2016 – OneCare Vermont