Vermont's blueprint for medical homes, community health teams, and better health at lower cost

System: The Vermont Blueprint for Health is a statewide public-private initiative to transform care delivery, improve health outcomes, and enable everyone in the state to receive seamless, well-coordinated care.

Key Innovation: Having community health teams work with primary care providers to assess patients’ needs, coordinate community-based support services, and provide multidisciplinary care for a general population. A web-based central health registry will capture all patient data.

Cost Savings: A recent analysis of the first pilot program found significant year-over-year decreases in hospital admissions and emergency department visits, and their related per person per month costs. Further savings are forecast once comprehensive financial reform is in place. When rolled out statewide, the initiative is projected to save 28.7 percent in incremental health spending in the state by its fifth year.

Quality Improvement Results: A qualitative assessment of pilot sites suggests that providers and patients value the role of community health teams in connecting patients with behavioral health, chronic care management, and social services support. Objective assessments suggest early improvements in clinical quality and use, such as better control of hypertension.

Challenges: For the initiative to be financially successful, there must be a measurable reduction in avoidable emergency department visits and hospitalizations. Insurers must shift spending away from remote call centers, disease management, and mailings, and into support for community health teams.