In Vermont, as in all states, chronic illness takes an enormous toll on people's lives and resources. Fifty-one percent of all Vermonters have one or more chronic conditions; nearly 80 percent of the $3.7 billion that was spent on health care in the state in 2007 went to treat chronic conditions.

Nationally, more than 80 percent of health spending goes to treat conditions such as diabetes, hypertension and cancer. But all this money doesn't buy consistently good care.  According to a 2004 RAND report, 50 percent of the care for the chronically ill is inadequate, which leads to higher costs and worse health outcomes.

While many states are adopting disease management programs for the chronically ill, Vermont is the first state to launch what it hopes will become a state-wide collaborative system of care for the chronically ill.

The state has been focused on chronic illness since 2003, when Governor James Douglas introduced the "Blueprint for Health, Chronic Care." The Blueprint, which was endorsed in 2006 by the Vermont General Assembly as part of the state's larger health reform package (Act 191), is designed to enable Vermonters with, and at risk for, chronic disease to lead healthier lives.

In 2007, lawmakers passed legislation(Act 71) that "enhanced" the Blueprint and authorized the creation of "medical homes" for the chronically ill.  These homes will bring together patients who will learn how to manage their conditions, providers who will oversee the patients' care, a health-care team to provide individualized support to the patient, and patients' local communities.  This month, the state will roll out the first of three pilot tests of its medical home concept in the town of St. Johnsbury. The state expects to have between 10,000 and 15,000 active patients in the program once it is fully operational.

Local Involvement Crucial
If the state was crucial to laying out the groundwork for the Blueprint, local communities are essential to its implementation. "There are a number of community efforts going on to help people with chronic conditions better manage their conditions on their own," said Representative Steven Maier, chair of the House Health Care Committee. "We became convinced that the community-coordinated model, focused around a medical home, was the most effective approach to take." 

“From the outset, the strategy for improving chronic illness care has been built around [a system] at the community level,” agreed Dr. James Hester Jr., director of the Health Care Reform Commission for the Vermont General Assembly. Starting pilots in a small number of communities “also educates us on the issues involved so that we can learn how to do it better in the next community.  The goal is to expand the number of communities over time and eventually be statewide."

The Medical Home
The Blueprint's medical home model is designed “to change the way primary care providers operate their practices," by encouraging more comprehensive and coordinated care, says an official at the Vermont Department of Health.  But the home extends far beyond the patient and provider—it involves the patient's family, which is often the most powerful influence on individuals and the health choices they make. It also includes the community, which can help prevent illness and promote good health by, for example, supporting exercise programs and building walking trails.

Primary care practices in the state of Vermont are typically small, with between two and five practitioners and most do not have the staffing infrastructure to support the medical home model. To fill the staffing gap, community-care coordination teams will help connect the patient to the provider and the community. Consisting of four or five individuals, the teams will allow practitioners to better follow up with chronically ill patients. 

Teams will include one or two members with clinical skills, typically nurses, a public health specialist and one or two non-clinical, community health workers. Community health workers are vital members of the team, because they "are well-versed in community resources, as well as in coaching techniques to support behavior changes," said Dr. Hester. "This concept of broadening the team of people who are involved in chronic illness care management is absolutely essential."

To support the medical home model, the legislature also changed how providers will be paid for care delivered under the pilots.  "Payment reform is key," said Representative Maier. "So many issues in health-care reform come back to how we pay our providers." 

Providers participating in the pilot programs will receive the typical service reimbursements, plus a care management fee. This fee is tied to the competencies as measured by the National Committee for Quality Assurance's (NCQA) patient-centered medical home model.  Under the NCQA criteria, specific points are assigned for different capabilities, such as the adoption of evidence-based guidelines for three chronic conditions; active patient self-management support; and the systematic tracking of test results and identification of abnormal results.  

As a practice's skills and competencies increase, payments increase along a sliding scale.  Using the NCQA criteria "was an important part of our concept," added Dr. Hester.  "We are trying to tie this care management to a national standard."

The three major private insurers in the state have agreed to participate and make financial contributions to the pilot programs.  Buy-in from commercial insurers was helped by the fact that the programs are being tested in only three communities, according to Dr. Hester.  The state's Medicaid program also will participate.  And the state has appropriated general funds to help finance the pilots.

Health information technology (HIT) will play a key role in operating the medical homes. Under legislation enacted in June, 2008, insurers in Vermont will pay a tax of .19 percent to establish HIT systems that will enable providers to perform such tasks as track their patients' care and progress, receive information on evidence-based care and identify patients who are at risk for additional conditions.

© Copyright 2008, State Health Notes