CHT Integration. The Contractor shall ensure coordination of services and activities and collaboration between the CHT staff (supported by the multi-insurer payments) and additional service layers and care managers for targeted populations, such as: MAT nurses and addiction mental health counselors for office-based treatment of opioid addiction (supported by Medicaid payments through the CHT funding mechanism and staffed by the Contractor with support from the Project Manager, either as direct hires or through subcontracting agreements) Support and Services at Home (SASH) nurses and care coordinators for Medicare beneficiaries living in congregate housing or in the community for assistance with aging safely at home VCCI nurse case managers for intensive, short-term treatment of the top 5% of high-utilizing Medicaid patients Commercial payer case managers The Project Manager shall document: Respective roles of the Core CHT and other care management providers Clear referral protocols and methods of communication between area care management programs Well-coordinated and non-duplicative services for participants CHT integration shall involve: Identification of case managers in the HSA for different populations of patients Determination of lead care coordinator for shared patients Joint care plans and agreements for managing shared patients Reciprocal referral protocols and methods of communication Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity
XI. Contractor will use meaningful and proactive measures to actively involve and include local health and human services providers in CC forums and encourage their participation at CC forums.
XII. Contractor will ensure collaboration of care coordinators and case managers within the HSA to reduce duplication of services, ensure smooth transitions of care, and increase patient satisfaction and will demonstrate this collaboration through documentation, including: Updates to role descriptions for the lead care coordinator and care team members, including responsibilities Updates to documentation of referral and communication protocols Updates to criteria for identifying lead care coordinator for shared patients Counts of shared care plans across organizations Outcomes from local care management learning collaboratives
CHT Integration. The Contractor shall ensure coordination of services and activities and collaboration between the CHT staff (supported by the multi-insurer payments) and additional service layers and care managers for targeted populations, such as: Medication Assisted Treatment (MAT) nurses and addiction mental health counselors for office- based treatment of opioid addiction (supported by Medicaid payments through the CHT funding mechanism and staffed by the Contractor with support from the Blueprint Project Manager, either as direct hires or through subcontracting agreements) Support and Services at Home (SASH) nurses and care coordinators for Medicare beneficiaries living in congregate housing or in the community for assistance with aging safely at home Vermont Chronic Care Initiative (VCCI) nurse case managers for intensive, short-term treatment of the top 5% of high-utilizing Medicaid patients Commercial payer case managers The Project Manager shall document: Respective roles of the Core CHT and other care management providers Clear referral protocols and methods of communication between area care management programs Well-coordinated and non-duplicative services for participants CHT integration should involve: Identification of case managers in the HSA for different populations of patients Determination of lead care coordinator for shared patients Joint care plans and agreements for managing shared patients Reciprocal referral protocols and methods of communication Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity
