At the Intersection of Health, Health Care and Policy

doi: 10.1377/hlthaff.2011.016930, no.3 (2011):383-386Health Affairs 

Health At Lower CostVermont's Blueprint For Medical Homes, Community Health Teams, And Better

Christina Bielaszka-DuVernayCite this article as:

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By Christina Bielaszka-DuVernay

INNOVATION PROFILE

Vermont’s Blueprint For MedicalHomes, Community Health Teams,And Better Health At Lower Cost

SYSTEM The Vermont Blueprint for Health is a statewide public-privateinitiative to transform care delivery, improve health outcomes, andenable everyone in the state to receive seamless, well-coordinated care.KEY INNOVATION Having community health teams work with primary careproviders to assess patients’ needs, coordinate community-based supportservices, and provide multidisciplinary care for a general population. Aweb-based central health registry will capture all patient data.COST SAVINGS A recent analysis of the first pilot program foundsignificant year-over-year decreases in hospital admissions and emergencydepartment visits, and their related per person per month costs. Furthersavings are forecast once comprehensive financial reform is in place.When rolled out statewide, the initiative is projected to save 28.7 percentin incremental health spending in the state by its fifth year.QUALITY IMPROVEMENT RESULTS A qualitative assessment of pilot sitessuggests that providers and patients value the role of community healthteams in connecting patients with behavioral health, chronic caremanagement, and social services support. Objective assessments suggestearly improvements in clinical quality and use, such as better control ofhypertension.CHALLENGES For the initiative to be financially successful, there must be ameasurable reduction in avoidable emergency department visits andhospitalizations. Insurers must shift spending away from remote callcenters, disease management, and mailings, and into support forcommunity health teams.

Vermont is in the vanguard of statesreforming the delivery and fundingof health care. With the passage ofVermont’s Health Care Affordabil-ity Act in 2006 and subsequent

health care–related legislation, the state is mov-ing toprovide all Vermonterswith access tohigh-quality, affordable care. Universal coverage is inprogress, largely through expanded access toMedicaid along with subsidized coverage forlow-income citizens. Vermont is also oneof eight

states chosen for the Centers for Medicare andMedicaid Services’ (CMS’s) patient-centeredmedical home demonstration project, knownas the Multi-Payer Advanced Primary Care Prac-tice Demonstration.1

The Vermont Blueprint for Health, launchedin 2003 and codified into law in 2006, is anintegral part of the state’s participation in theCMS project. Based on a foundation of medicalhomes supported by community health teams, itaims to deliver comprehensive, well-coordinated

doi: 10.1377/hlthaff.2011.0169HEALTH AFFAIRS 30,NO. 3 (2011): 383–386©2011 Project HOPE—The People-to-People HealthFoundation, Inc.

Christina Bielaszka-DuVernay(cmd6@columbia.edu) is afreelance editor and writerbased in Baltimore, Maryland,and is the former editor ofHarvard Management Update.

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care to the general population and improvehealth outcomes while controlling costs. All citi-zens in the state will be able to participate, with-out having to make copayments, obtain priorauthorizations, or meet eligibility criteria. “Itstarted as a chronic care initiative to make theChronic Care Model [developed by Ed Wagner]2

comealive across the state,” saysCraig Jones, theBlueprint’s director. “But it has evolved into atrue transformation of the delivery system. Thisis really a new approach, where we’re going tohave broad, multidisciplinary care support forthe general population, not just a targeted pop-ulation.”The Blueprint calls for advanced primary care

practices to serve as medical homes for the pa-tients they serve, with comprehensive supportfrom community health teams and an integratedinformation technology infrastructure. Eachcommunity health team is staffed by five full-time-equivalent employees and serves a popula-tion of approximately 20,000. The compositionof any particular community health team is de-termined locally, with input from area practicesand hospitals, but teams typically include nursecoordinators, behavioral health counselors, andsocial workers.The initiative is now operating in three pilot

sites and serves 60,000 people, or about 10 per-cent of Vermont’s population: the St. JohnsburyHospital service area, launched July 2008; theBurlington Hospital service area, launched Oc-tober 2008; and the Barre Hospital service area,launched January 2010.

With the recent enactment of enabling legis-lation, Vermont is shifting from pilot to full pro-gram, and statewide expansion of the Blueprintmodel is under way. Operations have started inthe Bennington area and will soon start in theMt. Ascutney/Windsor area. The authorizingstatute calls for at least two practices in eachservice area by July 2011, with all willing pro-viders able to participate in the program by Oc-tober 2013.Expansion planning in all service areas is

supported by Evaluation Quality ImprovementProgram facilitators, a scoring team based atthe University of Vermont, and several other or-ganizations. Vermont Information TechnologyLeaders is developing the statewide health infor-mation exchange and helping providers achievemeaningful use of electronic records.3 CovisintDocSite hosts the Blueprint’s central registryand assists practices and community healthteams with its use.4 The Vermont Program forQuality in Healthcare and Fletcher Allen HealthCare, which is affiliated with the University ofVermont, are part of a network that providestraining across the state to assist primary carepractices in adopting the patient-centered medi-cal home model.Proponents of the Blueprint say that lessons

learned in Vermont will help inform nationalefforts to implement health care reform. Jonespoints out that the state’s Democratic legislatureand its Republican governor, Jim Douglas, to-gether launched Vermont’s efforts. “Vermonthas been working on universal coverage formany years, as well as a number of quality im-provement initiatives,” Jones says. “There is aculture of working together across the state thatis extraordinary and important, and a culture ofwellness and prevention. These things togethermake Vermont a great laboratory for implement-ing health care reforms.”

Community Health TeamsJust as important to the Blueprint model as thepatient-centeredmedical home is the use of com-munity health teams, which provide a cruciallinkbetweenprimary careand community-basedprevention of chronic disease. They offer indi-vidual care coordination, health and wellnesscoaching, and behavioral health counseling,and they connect patients to social and economicsupport services. In addition, they perform com-munity outreach to support public health initia-tives. The teams’ role is to enhance patient careboth directly and indirectly: through individualservices performed on the patient’s behalf andthrough their support of individual providersand practices.

A community health team conducts a meeting in St. Johnsbury Hospital in Vermont. Inthe Vermont Blueprint for Health model, community health teams create a crucial linkbetween primary care and community-based prevention of chronic disease. They offerindividual care coordination, health and wellness coaching, and behavioral healthcounseling, and they connect patients to social and economic support services.

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Each community health team is led by a regis-tered nurse, who performs clinical duties andsupervises the team. The team includes one ormore additional registered nurses, who workwithin physician practices. Their primary dutiesare to trackpatientswhoareoverdue for appoint-ments or tests, manage short-term care for high-needs patients, check that patients are fillingprescriptions and taking their medications ap-propriately, and following up with patients ontheir personal health management goals. Thebehavioral health counselor also works in pri-mary care practices, helping providers identifypatients with untreated depression or substanceabuse, and intervening quickly when necessary.The fact that the counselors work in a familiarsetting lessens the reluctance somepatients haveto seek mental health treatment.Community health workers on the team help

patients fill out insurance applications, followtreatment plans, manage stress, and work to-ward their personal wellness or disease-manage-ment goals. In some cases, community healthworkers accompany patients to appointmentsand help them find transportation or child care.Public health specialists coordinate efforts be-tween the community health team and publichealth initiatives to reduce common health-riskbehaviors, as well as contributing to large-scalepreventive efforts. Dietitians work with patientswho have diabetes and other patients who neednutrition education and support.“The model places a big emphasis on better

self-management,” Jones says. “We’ve had goodsuccess with individuals and even families set-ting health goals regarding diet, exercise, andsmoking cessation.” At the same time, he says,the teams benefit providers, too. “Now they havego-to people for patientswho [have or are at highrisk for] depression or who need help gettingsocial services,” says Jones. “Solo providers,small practices, health centers—whether inde-pendent or hospital-affiliated—are all going tobenefit, and their patients and their patients’families are all going to benefit from the supportof the community health team.”Jones emphasizes that the communication

and connections do not flow just one way, fromtheprimary carepractice outward. “The idea is togo inall directions,”he says. “Say apersoncomesinto a local district office for social support ser-vices or heating assistance. If the social servicesperson finds out the person doesn’t have a pri-mary care practice or medical home, he or shehas people to contact who can connect the per-son to a provider.”As the pilots mature and more are launched,

Jones expects that the community health teams’impact will increase. “Our idea is that [the] core

community health team, by working with prac-tices and other service providers, will create aweb of close connections that will expand out-ward to form a much bigger functional commu-nity health team. This model has a synergy and ascalability that’s hard tomeasure but [that]we’realready seeing come alive,” Jones says.

Funding In The Blueprint ModelPrimary care practices taking part in the pilotscontinue to receive fee-for-service paymentsfrom insurers and Medicaid. In addition, theyreceive a per person per month payment basedon their National Committee for Quality Assur-ance score against patient-centered medicalhome standards. A team based at the Universityof Vermont scores the practices at baseline andevery six to twelve months and submits thescores to the National Committee for QualityAssurance for review and formal recognition.The payment that a practice can receive rangesfrom $1.20 to $2.39, and rises or falls $0.08 witheach five-point change in score.“Our insurers are still paying fee-for-service;

we couldn’t turn that off, even though therewerepeople whowanted to,” Jones says. The upside isthat all insurers can participate; the downside isthat the system “promotes volume, as we allknow,” he observes. “Butwith the enhanced pay-ment, we are beginning to balance qualityagainst volume, although we still have a longway to go.”Each community health team employs the

equivalent of five full-time-equivalent staffmem-bers, at an annual cost of $350,000. The com-munity health team is considered a core re-source, and its cost is shared among Vermont’sthree major commercial insurers as well asMedicaid. “For the pilots, we’re subsidizingMedicare,” Jones says. “With the announcementofMedicare’s becoming part of Vermont’sMulti-Payer Advanced Primary Care Practice Demon-stration pilot, we will truly have all payers in-volved when we roll it out statewide.”

Outcomes: Better Health, PatientAnd Provider SatisfactionThe Vermont Child Health Improvement Pro-gram performed a qualitative assessment ofthe Blueprint pilots in early 2010 and submittedits findings to theVermontDepartment of PublicHealth on June 30, 2010. The positive impactthat community health teams have had on prac-tices and their patients was the most often citedadvantage of the Blueprint initiative.Patients with chronic conditions were being

seen more frequently, according to focus-group

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discussions. Those who had been seen once peryear, on average, were now being seen up to fourtimes annually. Providers also said that having abehavioral specialist on the community healthteam and working at the practice site made itmore likely that patients referred for mentalhealth services would actually obtain them.Providers said that they felt they could re-

spond to a range of patient needs—nonclinicalas well as clinical—with the community healthteam’s support. As physician Dana Kraus ofSt. Johnsbury Family Health puts it, “Havingaccess to the community health team removesthe fear of asking a patient the simple open-ended question, ‘So, how are things?’ If the pa-tient breaks into tears or admits that things athomeare chaotic, I donot feel that I need to solveall of their social woes then and there bymyself. Ihave a whole team to help. I can have them seeBetsy, our behavioral health provider, withinthe week, or have Erica, our chronic care co-ordinator nurse, come right in and help sortout which resources they need. It truly expandsmy ability to care for patients by helping to tear,take, or break down social barriers that interferewith medical care.”A recent analysis of utilization patterns and

costs for the St. Johnsbury pilot—the first one,launched in July 2008—found significant de-creases from one year to the next in hospitaladmissions and emergency department visitsper 1,000 patients, and their related per personper month costs: Inpatient use and per personpermonthcostsdecreased21percent and22per-cent, respectively. Emergency department usedeclined 31 percent, and associated costs per

person per month fell 36 percent. And overalluse and costs per person per month dropped 8.9percent and 11.6 percent, respectively.5

ChallengesFor the Blueprint initiative to be financially suc-cessful, says Jones, there must be a measurablereduction in avoidable emergency departmentvisits and hospitalizations, and insurers mustshift spending away from remote call centers,disease management, and mailings and intocommunity health teams. “We’re asking themto do this by year 3,” he says. Comprehensivedata integration, sound assessment methodolo-gies, and ongoing support and improvement arealso critical. “To really roll out and expand acommunity-based system of care like this, andsee cost savings from it, there has to be realsupport,” he notes. “We’re working on buildinga primary care extension service and other infra-structure, and collaborating closelywith theUni-versity of Vermont on analytics and ongoingquality improvements.”For now, Jones and state officials believe that a

10–15 percent reduction in hospital admissionsis achievable. Building a guideline-based systemof care delivery may also reduce excess use. Ascurrent projections stand, total health spendingin the state, now at $320 million, is projected torise by another $100 million within five years.When fully rolled out statewide, however, Ver-mont Blueprint for Health could save 28.7 per-cent of that increase—savings that could makethe most skinflint of Vermont Yankees proud. ▪

This paper was commissioned by HealthAffairs and is based partly on apresentation by Craig Jones, VermontBlueprint for Health, that was deliveredat a Health Affairs conference,Innovations across the Nation in Health

Care Delivery, December 16, 2010, inWashington, D.C. For a copy of theagenda and a full list of conferencesponsors, please visit http://www.healthaffairs.org/issue_briefings/2010_12_16_

innovations_across_the_nation_in_health_care_delivery/2010_12_16_innovations_across_the_nation_in_health_care_delivery.php.

NOTES

1 Centers for Medicare and MedicaidServices. Multi-payer Advanced Pri-mary Care Practice (MAPCP) Dem-onstration fact sheet [Internet].Baltimore (MD): CMS; 2010 Nov 3[cited 2011 Feb 7]. Available from:https://www.cms.gov/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf

2 Improving chronic illness care[home page on the Internet]. Seattle(WA): Group Health Research Insti-tute; c2006–11 [cited 2011 Feb 22].

Available from: http://www.improvingchroniccare.org

3 Vermont Information TechnologyLeaders Inc. [home page on the In-ternet]. Montpelier (VT): VITL;c2010 [cited 2011 Feb 22]. Availablefrom: http://www.vitl.net

4 Covisint. Covisint DocSite [homepage on the Internet]. Detroit (MI):Compuware-Covisint; c2010 [cited2011 Feb 22]. Available from: http://www.covisint.com

5 The multipayer claims database,

VHCURES, includes commerciallyinsured patients only. VermontHealthcare Claims Uniform Report-ing and Evaluation System [homepage on the Internet]. Montpelier(VT): Department of Banking, In-surance, Securities and Health CareAdministration; c2011 [cited 7 Feb2011]. Available from: http://www.bishca.state.vt.us/health-care/health-insurers/vermont-healthcare-claims-uniform-reporting-and-evaluation-system-vhcure

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Errata

Levit et al., May 2013, p. 957 The titleof Exhibit 4 erroneously included “AllHealth.” Values for “all health” are notpresent in the table. Also in Exhibit 4,the row “Substance use provider spend-ing, millions” contained incorrect data.

The correct values in that row are asfollows. 1986: $8,562; 1992: $12,860;1998: $13,919; 2004: $19,434; 2007:$21,975; and 2009: $21,932. The exhibithas been corrected online.Bielaszka-DuVernay, March 2011,p. 383 This article stated that theVermont Blueprint for Health was

launched in 2006. The Blueprint wasactually launched by Gov. Jim Douglasin 2003 and, after three years of imple-mentation, was codified into law in2006. The article has been correctedonline.

1336 Health Affairs JULY 2013 32:7