Common use of CHT Integration Clause in Contracts

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 Agreement Deliverables

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 Medication Assisted Treatment (MAT) nurses and addiction mental health counselors for office-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  VCCI 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 shall 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 Agreement Deliverables

CHT Integration. The Contractor shall ensure coordination of services and activities and collaboration between the CHT staff (supported by the multi-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 Agreement Deliverablesacuity

CHT Integration. The Contractor shall ensure coordination of services and activities and collaboration between the CHT staff (supported by the multi-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 Agreement Deliverables